Latest Entries »

Walking

Today I did something unusual. I left early. It’s near the end of the semester. This is the time of year when everything is due at once, but it is also the time of year when the sun comes out for the first time in months. I looked out the window at the blue sky and I decided that the PowerPoint I was making could wait. So I went for a walk. I followed a surprisingly empty bike path near the river. I successfully passed by two joggers, one biker, and an entire women’s rowing team without having to talk to anyone. I brought my camera along and got a few pictures of the evidence that spring is spreading.

As I walked, my mind kept returning to the presentation that I had been putting together, which was on the topic of gait and balance. I have been fascinated by the way people stand and walk ever since I was a kid, this interest is what got me into sports medicine, and then into the field of orthotics and prosthetics and now into my PhD research. This semester, I am collecting data on a project that measures people’s balance when they are standing in various conditions. I am also the TA for an undergraduate biomechanics class. The presentation I am putting together is for a class lecture that will hopefully help the students think about ways to apply their newly acquired understanding of biomechanics to their future careers in rehabilitation science. I thought talking about walking would a good way to do this.

I just want to be able to walk  ________”  Fill in the blank.  Some patients say again, some say without pain, some say for the first time, or down the aisle at my wedding, to the mailbox, or up a mountain. I have heard variations of that sentence hundreds of times. For many people, the line between disability and normality is drawn at the ability to walk. If walking is unavailable, we will settle for alternate forms of transport – like wheelchairs or mobility scooters. But walking does seem to be the preferred method. Last year I had the opportunity to participate in a research project about mobility of the elderly within the home environment. We interviewed the participants about how well they were able they were to move around their homes, we measured their walking ability and we measured their homes. Mobility is a result of two different factors – the person’s physical abilities and the challenge of their environment. This becomes clear if you consider two extreme scenarios:

1)   A rock climber can use his extraordinary fitness and skill to conquer a cliff face.

Mobility2

2) An old woman uses all of her strength to reach the top of a flight of stairs.

mobility3

The amount of effort might be similar in both situations. In both cases, the individual is pushed to the limit to overcome a barrier. The only differences are the size of the barrier, and the extent of the physical limitations. This afternoon as I was walking along a smoothly paved bike path, I was well within my mobility “comfort zone”. I was able to enjoy the scenery and let my mind wander without having to struggle through each step. It’s a privilege to be able to do that.

In 2015, the Center for Disease Control estimated that limited mobility was the most common form of disability in the United States, impacting about 13% of adults. The National Health Interview Survey found similar results, stating that about 18.2 million adults in the US are unable to walk even 1/4 of a mile.

Mobility4

There were mile markers on the trail that I was walking along, placed every quarter of a mile. Each time I passed one I was reminded of these statistics. Besides feeling fortunate to have the ability to walk, I was also feeling excited to have picked such an intriguing area of research and clinical practice. Gait and balance impact so many aspects of a person’s life, these abilities can be threatened by myriad conditions and restored via many therapeutic interventions. This means job security and ample opportunity to make a positive difference. Tomorrow I will go back to preparing the PowerPoint. I will turn these rambling thoughts into tidy bullet points, and then I will deliver them to a hall full of sleepy students. Maybe I can change the way that some of them think about walking.

 

Walk well!

 

Advertisements

ICD-10

Don’t panic

Do you remember the Y2K scare? When the calendar year turned over from 1999 to 2000 there was widespread fear that our computer-driven society would suffer some sort of mass meltdown and that apocalyptic-style crisis would ensue. It didn’t. 1/1/2000 was a day much like every other. All those stocks of canned goods and bottled water went unused, nothing exploded, no missiles launched – and we all breathed a sigh of relief.

Well, tomorrow (10/1/15) marks the first day of a new era in the medical world. The beginning of the ICD-10 diagnosis code system. It is a big, scary change; everybody hopes it goes smoothly, but if it doesn’t – it could be Y2K 2.0. The change-over has been put off for the last several years because of the huge amount of preparation it takes to ready the medical software and billing systems for the transition.

Keep calm and …

For those of you unfamiliar with diagnosis codes, here is a little look behind the curtain. When you go to your doctor for an appointment, you describe your symptoms, the doctor examines you and eventually comes up with a diagnosis. The doctor then writes an office note about your visit, recording any significant findings and maybe a line or two about the symptoms you described. The note is as short as possible since the doctor has to move on quickly to the next patient. This note is then made a part of your medical record and can be accessed in the future to verify what happened at that day’s appointment. One important component of your office note is the diagnosis code. This is a short sequence of numbers that describes what injury or illness you have.

This diagnosis code is included on a prescription that is then sent on to your pharmacy, any therapist who will be giving you treatment or anyone who might be fitting you for a brace or medical appliance. The diagnosis code is the only information that we (your Pharmacist, Therapist… in my case, Pedorthist) have about your condition unless we request a copy of the chart notes from the doctor. The diagnosis code is also the only information your insurance company has about your doctor’s appointment.

Follow the money

In an effort to be as profitable as possible, insurance companies do their best to avoid payment for what they deem to be unnecessary treatment. As a result, insurance companies check to make sure the diagnosis code matches a list of approved codes before agreeing to pay for any treatment. For example, if your doctor has prescribed that you wear a knee brace, your diagnosis code must be for a knee injury. The brace might be denied as “not medically necessary” if you just have a diagnosis for a knee bruise, since a bruise is not considered a serious enough injury to require a brace.

Usually this system works pretty well, the insurance companies save money by not paying for unnecessary things. The patients feel vaguely that their insurance coverage is not what it was cracked up to be, but they can’t do anything about it so they pay their bills and move on. Everybody (by which I mean the insurance company and the doctor) is happy. However, this already somewhat dysfunctional system is about to turned on its head.

Old vs. New

The old diagnosis code system was called ICD-9. It contained about 17,000 codes for your doctor to select. Most of the time, it was pretty easy to find a code that somewhat described your problem. If you only had 1 thing wrong with you, you might only have 1 diagnosis code, if you had multiple issues the doctor might use a combination of codes to describe your condition. ICD-9 codes also contained handy “catch-all” codes like this one (my personal favorite) 729.5 which means “pain in unspecified limb”. Ha ha. That’s like saying “Doctor, my leg hurts” and having him say “yes, that’s because your leg hurts…that’ll be $75 please”. But, I digress…

The new ICD-10 system contains 69,000 codes. This means that the physician must be much more specific about what exactly is wrong with his patient. Which is a good thing, it means that each patient’s medical record will now be more complete and contain a lot more information. No more lazy diagnoses, the codes now indicate if this is a new or old condition, how it occurred, and a lot more details about what exactly is wrong. There is a code for everything, this is an actual, real code:  W59.22XA = Struck by a turtle, initial examination. How does that even happen?

What does this mean for you?

Unless you are in the healthcare industry, you don’t have to change much about your daily routine after tomorrow. You may not even notice the transition from ICD-9 to ICD-10. But if (as I suspect) the change-over is a little bumpy, you may notice a snafu or two. For one thing, it will now be easier for an incorrect diagnosis code to be applied to your chart. The physician choosing the code is most likely working with software that helps him choose from a list of possible diagnoses, these lists are long and confusing. It is very easy to click the wrong code and next thing you know you have been diagnosed with an injury from a turtle strike.

You, as the patient, should always know what your medical record says. You can help ensure continuity of care by being well-informed. Remember, you are one of many patients being seen in a busy office and it is very easy for mistakes to be made. You are in charge of yourself. Be your own advocate and make sure a simple data entry error isn’t getting in the way of your treatment. You can google your ICD-10 codes to make sure that they make sense. If you have a question, don’t be afraid to ask. (But as a tip, be cognizant of the fact that your doctor is probably in a hurry – be brief, be courteous).

The other thing you need to know is that insurance approvals might take a little bit more time than usual in the next few weeks. This is because they are busy checking everybody’s new codes to make sure that the treatment is still “medically necessary”. With these new, more complicated codes there is much more information to sift through.

If you have any kind of doctor’s appointment tomorrow, bring a treat for your physician and especially for the office staff. It is going to be a long and hectic Thursday. Expect delays. Hopefully this new system will lead to better quality care in the long run. Only time will tell.

Walk well!

Plantarflexion Contactures

A contracture happens whenever a muscle gets stuck in its shortened position- making the joint have less motion than it should. In the case of a Plantarflexion contracture, the joint in question is the ankle. The muscles on the back of your calf are called the Plantarflexors. Here is a picture of those muscles:

Plantarflexors 3D

The plantarflexor muscles are anchored behind the knee and are responsible for pulling up on the back of the heel, which makes the toes point downwards. This is called a plantarflexed position.

Plantarflexor motion

When the muscles in the back of the calf are in contracture, it means that the person is unable to move his or her foot into normal position. (The opposite of plantarflexion is a motion called dorsiflexion, which means bringing your toes up. See the picture below). Dorsiflexion can only happen if the muscles in the back of the calf are able to be stretched.

Dorsiflexion motion

The yellow line in both pictures represents the “neutral” position of the foot. In order to walk normally, you have to be able to move your foot a few degrees beyond this line. This becomes impossible if the plantarflexor muscles are contracted.

degrees of contacture

Moderate to severe Plantarflexion contractures occur very frequently in people who have been born with Cerebral Palsy, had a stroke or suffered some sort of injury. More mild versions of a Plantarflexion contracture can happen to anyone. As you can see in the picture above, the mildest form of Plantarflexion contractures just means that you are unable to pull the front of your foot up towards you past the neutral position.

I have found that VERY MANY people who complain of foot pain have a mild case of Plantarflexion contracture. There are two reasons for this high correlation:

  1. If you have really tight Plantarflexor muscles you probably also have a very tight Plantar fascia. This is because the two are very closely related. See this previous post about the topic of a tight fascia and tight calves. https://walkwellstaywell.wordpress.com/2012/09/05/plantar-fasciitis-a-real-pain-in-the-arch/

 

tight calves = sore fascia

  1. If you have a Plantarflexion contracture you are probably spending a bit more time walking on the front part of your foot since you are already in “tip-toe” position. This means that instead of distributing your body weight over the entire foot, a lot of stress is concentrated at the front your foot (The metatarsal region).

 

Toe walking with diagram

 

 

Walking with a Plantarflexion contracture is not only bad for your feet, it can also effect the rest of your body – especially the hips, back and knees.

knee hyperextension                                       lack of dorsi-valgus knee

People with Plantarflexion contractures tend to compensate by moving their knees into bad alignment when walking or standing. This causes stress to the knee joint because if forces the knee to be in an unnatural position. The hamstrings then get sore and tight, they pull on the hip which then puts extra strain on the back. The net effect is to make the person’s feet, legs and back feel sore and tired.

Now when someone with a Plantarflexion contracture comes to me for treatment, I am faced with two options:

I can make them feel better

Or

  1. I can help them actually get better

 

In order to make someone with a Plantarflexion contracture feel better, all I have to do is put a wedge underneath their heel inside of their shoe. (Or instruct them to wear a shoe with an elevated heel). This solution essentially brings the floor up to the foot – It makes up for the fact that the person cannot get his or her foot into the neural position. In fact, it encourages the foot to remain in a nice relaxed Plantarflexed position. So what’s the problem with that? Well, it’s fine as long as the person can always have a wedge under their heel. But it means that they will no longer be comfortable walking without their shoes on. They are now dependent on the heel elevation to be able to walk without pain. This position becomes their new “normal”. If maintained long enough, the foot loses its ability to dorsiflex even to the neutral position. The patient has now moved to a more severe level of Plantarflexion contracture.

Heel lift

In order to actually chose option #2 and recover from a Plantarflexion contracture, the patient needs to be encouraged to do just what the foot doesn’t want to do – Dorsiflex. In other words, they need to stretch. Aggressively! The plantarflexor muscles are very tough and strong and they are not going to give up without a fight. Research suggests that if you are stretching to overcome a Plantarflexion contracture, you will need to stretch for at least 30 minutes per day. You can read more about the topic of calf stretching in this blog post from a few years ago. https://walkwellstaywell.wordpress.com/2012/10/03/silly-putty-stretching-for-plantar-fasciitis/

towel

Now you know! Plantarflexion contractures happen all the time. And they are really bothersome once they are established. You can fight this problem by being diligent about your calf stretching. Pass the knowledge on:  Watch for anyone walking on their tip-toes or standing with hyperextended knees. Be alert for signs of achy foot pain in yourself and your family members. Direct them towards this blog for some further reading. That’s all for now – go and stretch your Plantarflexors….

 

Walk well!

Collaboration

Interdisciplinary Collaboration Graphic

A fellow blogger named David and I worked together to write an article about teamwork and cooperation in healthcare.

You can read our post here:

http://blog.davidbendell.com/2014/improved-interdisciplinary-collaboration-for-better-patient-safety/

It has been my experience that small, private healthcare practices, such as those in the field of Orthotics and Prosthetics, tend to operate very independently. Interactions with other members of the healthcare community are often limited to self-promotion aimed at referral sources and the occasional round-table discussion at annual conferences. This may have been an acceptable practice previously, but the world has changed. Information is now able to be exchanged at increasingly rapid rates, we no longer have the excuse that it is difficult to contact our colleagues. Patients benefit when their caregivers maintain open and clear communication.

What should you do? 

1. If you are a patient: You should not assume that your various caregivers are communicating adequately. Be sure that you have copies of all relevant documentation. Keep a set for yourself and bring your paperwork to your appointment. Take notes about what each caregiver is telling you. Be able to refer to these notes in case you seem to be getting confusing or conflicting information from different practitioners. This extra caution will ensure that you don’t fall through the cracks. Your doctors should never intentionally mislead or incorrectly treat you, but everyone makes mistakes… Even people who wear white coats.

2. If you are a practitioner: Reach out to your colleagues. Get to know the other practitioners in town. Don’t just view them as competition or as a referral source. Think of them as a fount of information that you can use to better treat your mutual patients.  Even those who vary drastically from you in terms of discipline type and education level possess specific skill sets and knowledge bases from which you can learn. Your patients will benefit from your willingness to collaborate with their other caregivers.

Walk well!

Varus and Valgus

This blog is about two of my favorite medical terms: Varus and Valgus. These words come from Latin and they basically are ways to refer to something that is crooked. Most of the time when I use “varus” or “valgus” I am referring to different types of crooked legs. Almost nobody has perfect legs – so most of us fit into the category of either varus or valgus leg alignment.

One of the first things I do when evaluating a new patient is to decide if their legs are varus or valgus.  I use these categories as very loose guidelines to help me quickly decide what types of injuries the person might be experiencing. It is not too surprising that people with similar body types often develop similar injuries.  Of course there are exceptions to every rule, and there also degrees of severity. Not everyone fits neatly into a category, but I find that this is as good a starting place as any.  Here is a brief overview of the Varus, Valgus and “Good” alignment groups.

Before we get too far into this, I need to stop for a disclaimer: Please excuse the poorly hand drawn pictures that resemble happily dancing robots. I am no Picasso. Or maybe I am too much of a Picasso (if you have seen some his cubist paintings).

Good alignment

Legs are considered to be in good alignment if a straight line can be drawn from the hip, through the knee to the second toe. Here is a guy with good alignment:

DSCN0113 (2)

Although this figure looks very smug about his perfect legs, you can’t always assume that people with good leg alignment will be injury free. Legs that are very straight sometimes have a hard time absorbing shock. Because all the bones are aligned exactly on top of each other, every step can send shock waves up into the rest of the body. This shock is often absorbed in the pelvis or spine, resulting in injuries of the back or even the neck.

 

Varus

A person with Varus alignment of their legs looks something like this:

DSCN0118 (2)

Varus alignment can also be called “Bow legged”. A person with varus alignment has legs that curve outward, with the knee being further out than the foot. The curving shape can happen at either the knee joint itself or because the actual bones of the lower leg are bent outward.

If you have trouble remembering the meaning of varus, remember that that R stands for Rounded.

DSCN0112 (2)

Varus legs are susceptible to the following injuries:

–          Osteoarthritis of the knee

–          Shin splints

–          IT band pain at the hip or knee

–          Chronic ankle sprains

The most common issue I see with people who have varus legs is knee pain. The varus leg shape is bad for both the medial (part on the big toe side) and lateral (part on the pinky toe side) areas of the knee. Because of the curved shape of the leg, all of the structures on the medial side of the knee are squished together and all of the things on the lateral side get stretched apart.

Varus knee

To make matters worse for the varus leg group, it is very common for someone with a varus knee to also have a varus foot alignment. This is also called having a supinated foot. Supinated feet look like this:

Supination of the foot

There is a whole list of additional problems that comes with having supinated feet. It will be the subject of its own blog post in the future. For now it is enough to say that people with supinated feet are more likely to sprain their ankles, since they put most of their body weight on the outsides of their feet.

 

Valgus

Valgus leg alignment is much more common that varus leg alignment. Someone with valgus legs stands with their knees close together, in a “knock knee” position.

DSCN0115 (2)

You can remember the term valgus because the leg forms an angle like the letter L

DSCN0110 (2)

Valgus leg shapes can lead to the following injuries:

–          Knee caps that dislocate

–          Medial knee pain

–          Patella/femoral syndrome (also called jumper’s knee)

–          Foot and arch pain

–          Low back pain

People with valgus leg alignment almost always have pronated feet.

This means that the weight of the body causes the arch of the foot to collapse and the person then stands with more weight on the inside portion of the foot.

Pronation of the foot

Valgus knee alignment (not surprisingly) puts exactly the opposite stresses on the knee as varus alignment does. The lateral side of the knee is squished and the medial side of the knee is stretched.

Valgus knee

People with valgus leg alignment often have pain in the front and the inside of their knees. This is because the angle of the leg causes an uneven pull on the kneecap. It is slightly more common for females to have a valgus leg shape because they tend to have wider hips.

 

The Combo:

It is also possible to have any combination of leg alignments:

DSCN0109 (2)

One leg could be valgus while the other leg is straight, one leg could be varus with the other leg is straight, or you could even have one of each! These combo arrangements often happen either as the result of a serious injury (like a fracture that didn’t heal well) or because one leg is significantly longer than the other.

 

So what should you do if you have varus or valgus legs?

–          Loose the extra weight. If you have varus or valgus leg alignment, the best thing you can do for yourself is to maintain a healthy body weight. Additional pounds can make a mild alignment issue much worse. Our legs have to work really hard to support us, even under the best of circumstances. People who naturally have excellent body alignment can often get away with being a bit heavier, but anyone who has varus or valgus legs should be very cautions not to make the issue more severe by gaining too much weight.

 

–          Do low impact exercises and activities. The stress associated with long distance running and other such repetitive activities can really prove damaging to people who have severe varus or valgus alignments.  Cross training and alternative exercise programs are a great way to overcome this. Try swimming or biking for your cardio workouts. You can still do some running, just keep it in moderation.

 

–          You might be able to somewhat improve your alignment by doing specially targeted stretching and strengthening exercises. Find yourself a physical therapist or fitness specialist who can help you set up a routine.

 

–          Sometimes the alignment issue is severe enough that a brace must be used on that leg. “Unloading” knee braces apply force to the side of the knee in an effort to reduce the angle of the joint.

 

–          Foot orthotics can correct the issue from the ground up – this can often reduce the amount of varus or valgus in the rest of the leg.

 

–          Remember that poor body alignment can lead to chronic injuries. Be careful with yourself! If you do develop one of these injuries, be sure that you treat it and allow it to fully heal so that it won’t come back to haunt you. Sometimes this means changing your usual activities… I’m looking at you, distance runners!

 

–          If the alignment problem is severe enough you will probably be referred to see an orthopedic surgeon. The orthopedic surgeon might tell you that a knee replacement surgery is in your future.

** Remember that surgeons make their living by doing surgeries – it is always ok to get a second opinion from someone who doesn’t stand to benefit from performing an operation on you. **

 

Walk well!

 Patient Centered Care

I accidentally majored in Therapeutic Recreation in college. It was not my first plan- in fact, I think it was “plan C”. I was originally all set to major in Athletic Training, but the program was cut down to a minor just before I was qualified to begin. Then I set my cap on an Exercise Science major only to have it morph into a Physical Education Teaching track, which did not thrill me at all. By this time I had accumulated a strange assortment of classes under my belt and I went where the wind took me. Which was in the direction of Therapeutic Recreation (also called TR). I wasn’t happy about it.

All the other TR majors were equestrian types who wanted to work at youth ranches and summer camps for troubled teenagers. I wanted to work in a clinical setting and treat patients who were recovering from orthopedic injuries. I was a snob about it. I thought to myself “These people don’t have any place in the world of Medicine” (Capital M to make it seem more important). “What am I doing here”, “This is beneath me”. Snobbery of the worst kind.

But, in spite of myself, I began to absorb things in my TR classes. In fact, I learned a lot of really useful theories, many of which I use on a regular basis now that I work at my clinical job.  The main point that was hammered home to me again and again was the concept of “Patient centered care”.

Patient centered care is all about putting the needs of the patient first. This seems like it would be a basic concept, but it turns out that it is not. All too often in medicine we spend our time treating the problems instead of taking care of the people.  This is the difference between putting a brace on a mildly sprained Left wrist and treating Doug, a mailman who slipped on the ice and sprained his wrist last week.

It doesn’t actually change the treatment at all. The same brace gets used for the same injury whether the wrist belongs to a mailman or rocket scientist. It doesn’t matter to the clinic, we get paid the same amount for the brace either way. But it does matter to Doug. He knows that I am conscious of the fact that he as a person is attached to his sprained Left wrist. We exchange a few words of genuine human conversation. I made a weak joke, he snickers slightly. He walks out with his wrist feeling better and his human dignity intact.

Patient centered care is actually really hard to do in real life. This is because medicine is a business. Businesses are all about efficiency. In order to reach maximum efficiency, facts are reduced to numbers and figures.

–          This is my 7th patient this afternoon

–          She is 65 years old

–          ICD9 824.4

–          His insurance will only cover 80% of the cost

–          5’5”, 195lbs

–          We are running 10 minutes behind schedule

–          Right TKA 3 months ago

–          L4360

–          15” calf circumference

Somewhere in the cloud of numerical facts, the practitioner has to find the time and presence of mind to actually talk to the patient as a person. And people are messy. They tell you their entire life story when you are just trying to get the history of the injury, they cough without covering their mouths, they smell bad. Last week I asked an elderly patient if she had any pain while I was evaluating her knee injury. She responded with “I don’t drink. Never touch the stuff”. Thankfully she was too deaf to hear me snort with laughter. I bellowed back at her “Neither do I”. She seemed satisfied.

iron man

I saw this picture on the internet on Monday. Window washers at a children’s hospital in North Carolina don superhero costumes while reppelling down the side of the building to clean the glass. How unnecessary and wonderful! I’m sure that this action doesn’t boost the productivity of the window washers. Imagine how annoying it would be to wear a cape and/or helmet when you are dangling from a harness 15 floors above the ground. It doesn’t make a whole lot of sense from a business perspective. But to the sick and injured kids in the hospital beds, this little extra act of kindness is a big deal.

Even though the patient centered care processes can sometimes be a challenge, it matters.  Talking to the patient, getting to know them slightly and going the extra mile to help them feel that they are valuable and important is a huge part of successful treatment.  Even though it may seem less efficient, this type of approach often garners superior results. This is because people’s feelings very much effect their health. Good feelings = feeling good.

For a more in-depth look at patient centered care, I recommend this article:

http://healthaffairs.org/blog/2012/01/24/patient-centered-care-what-it-means-and-how-to-get-there/

 

Walk well.

AFOs for Foot Drop

My last blog entry served as a bit of an introduction into the topic of AFOs. (If you didn’t read it, here is your chance). By way of quick review, AFO is an abbreviation that stands for “Ankle Foot Orthosis”.  Orthosis is the more formal term for a brace.

The number 1 most common reason for someone to wear an AFO is because they have a condition known as “Foot drop (or drop foot)”. Foot drop happens when there is weakness in a muscle group called the “Dorsiflexors”. These muscles run along the front of your lower leg and ankle. They are responsible for the action of lifting your toes up. The muscles in the Dorsiflexor group include the Anterior Tibialis, the Peroneus Tertius and the Extensors of the Toes.

Foot drop muscles

Sometimes when a person has foot drop, the Dorsiflexor muscles themselves are weak, but most frequently it is actually the nerve that runs to these muscles that isn’t functioning properly. Because it is so often a nerve problem, foot drop occurs many times in people who have had a stroke, brain injury or multiple sclerosis. It also common in people who are born with cerebral palsy, muscular dystrophy, CMT, or many other conditions. Foot drop can also be the result of a back or leg injury.

All of these Dorsiflexor muscles are controlled by a nerve called the “Common Peroneal Nerve”. This nerve is actually an extension of the Sciatic nerve which branches off the spinal cord at the lower back and runs all the way down through the leg. If this nerve is damaged at any point, there is a very good chance that the signals will be disrupted and some leg and ankle weakness will occur as a result.

Nerves of Foot Drop

Drop foot can range from mild weakness to complete paralysis of the effected muscle groups. People with mild foot drop sometimes only notice it when they are tired at the end of a long day. Many times mild cases of drop foot go unnoticed until the person begins to realize that they are tripping and falling more frequently than usual, especially on uneven surfaces.

Those with more severe drop foot usually walk with a very distinctive gait called a “steppage gait”. This is where the person picks their knees up especially high in order to allow their foot to swing forward without snagging on the ground. When the foot is placed down on the ground it usually hits with a slapping noise as the toes uncontrollably flap onto the floor.

Here is a little video demonstration:

 

 

The job of an AFO for someone with drop foot is to keep the toes from dragging while the person walks, and also to slow down the slapping motion as the foot is planted on the ground. A whole multitude of devices have been invented to do this task.

Very mild drop foot can be treated with devices like this:

mild foot drop options

More complicated cases of drop foot sometimes require custom molded AFOs with a variety of features. Here is a little photo gallery of typical drop foot AFOs:

Foot drop AFOs

Custom foot drop AFOs like these are made by Orthotists and Pedorthists. They are typically made from a cast of the patient’s leg. The AFO is then designed and fabricated exactly to the specifications of each individual patient. Custom AFOs usually work very well (if the person making it did a good job), but they have several draw-backs: It takes a long time to make them, they are super expensive and because they are made so precisely, they have to be adjusted and fine-tuned frequently to ensure that they fit correctly. If the AFO was made for a child, constant changes have to be made to accommodate growth. Even adults tend to lose and gain weight over the course of the years. These changes can jeopardize the fit of the AFO. A poorly fitting AFO is not as effective as it should be and it can even be dangerous because it could lead to falls or it could cause a sore on the skin.

Because of these complications, new solutions to foot drop are beginning to flood into the market. My personal favorite development is carbon graphite AFOs. These AFOs are lightweight and strong. They are low profile because they don’t have to include bulky joints like the old fashioned plastic AFOs. Many models of this type of AFO can be purchased completely ready to wear. This eliminates the long process of taking molds of the patient’s feet and making the AFOs from scratch. Many patients use a custom foot orthotic in addition to the carbon graphite AFOs in order to ensure total comfort and appropriate support.

The reason carbon graphite AFOs are so cool is that the material is springy which means that it provides energy return. This allows the person wearing the AFO to walk with a very smooth and natural gait. Some people are even able to run marathons, hike, bike, etc with the use of this type of AFO. Can you tell that I am excited about this technology? Here are some cool videos of people using a few of the more common carbon graphite AFOs:

 

 

before:

 

after:

one more:

 

 

These are just some examples of the new solutions to the problem of foot drop. I think that carbon graphite AFOs are the wave of the future. I am very interested in watching the evolution of the AFO as patients become more thoroughly informed about their treatment choices. Patients now have access to huge amounts of information in all sorts of formats (including possibly, dare we say – this blog). They can then use these facts and concepts to educate their caregivers and voice their opinions and preferences. This is great! It means that more and more people get to take advantage of the cutting-edge technology choices. This process then drives improvements and encourages the development of even newer and better AFOs. How exciting!

Walk well.

From tapes and braces to AFOs

Back in my days as a student athletic trainer, my favorite injury to take care of was a sprained ankle. I enjoyed them because they were a common occurrence and because ankle rehab is very involved and detailed.  My favorite part of the rehab process was when the athlete was ready to return to play and we would decide what sort of ankle support was needed to make sure that they were able to play a game without incurring any additional injury.  Usually our support method of choice was a solid ankle tape. Some of those tape jobs were works of art, incorporating all types of stretchy and supper strong tapes in with the plain white athletic tape. We did heel locks and figure 8s and figure 4s and extra stirrups and horseshoes and basket weaves.  When the tape was done we wanted to sign our names to it and take a picture of our handiwork. Taping was so fun, and it introduced me to the concepts of how to correctly support an injury in order to encourage healing while still allowing function. It was this experience that got me interested in braces.

 Ankle tape

In athletic training, we often fit an athlete with an ankle brace if they show signs of chronic ankle instability. The braces are more convenient for the athlete than getting an ankle tape every day.   Depending on the type of injury, we can choose between several kinds of ankle braces to decide which would provide the best stability and prevent re-injury.

When I was first getting into the field of Orthotics, I thought most of the ankle braces I would be making and fitting would be somewhat like the braces that we used in athletic training. How wrong I was! It turns out that I had failed to take one important consideration into account: Population. Athletic trainers work mostly with athletes (no surprise there).  Most Orthotists spend much of their time focused on patients with chronic conditions or disabilities. The majority of these patients are not going to be playing basketball any time soon.

Playing basketball with an ankle brace Walking with an AFO

Every once in an odd while these patients need ankle braces for the same sort of reasons that my athletes need to wear a brace: because they injured their ankle at some point and they need to protect the joint so that the injury doesn’t reoccur. I will categorize this as ligamentous instability. In other words, at some point this person severely sprained a ligament in their ankle and as a result the ankle is unstable. This the type of injury I was used to dealing with in the athletic training world. (And to tell you the truth, it is still my favorite…)

Ligaments (ankle sprains)

But there is a much bigger category of people with a different sort of ankle instability. This is the group of people with muscular instability. The ankle is a very complicated joint, which relies on an intricate system of small muscle groups to hold the foot in the correct position to allow you to walk and stand. The patients who are being treated by orthotists usually have some sort of weakness in one of these muscle groups. As a result of this deficit, the positioning of their foot and ankle is faulty and they are at risk of tripping and falling if they do not wear a brace. Because muscular weaknesses can lead to some unusual joint alignments, custom braces are often needed to accommodate the patient’s unique ankle structure.

Ankle muscles balance of forces

Here is a pretty dramatic video of a guy demonstrating how much better he can walk with the use of his custom ankle braces.

This leads me to another difference between the ankle braces that I was used to in athletic training and the braces from the field of Orthotics. Terminology. In athletic training and rehabilitation, we are content to call a brace a brace. But orthotists call a brace an “Orthosis”. If multiple braces are being spoken of, they are called “Orthoses”.  Therefore, if you hear someone referring to an ankle brace as an “Orthosis” you can bet that the brace was made by an orthotist. It is also a pretty safe bet to assume that the brace was either custom made for that person or at least custom fit to them. Because it is cumbersome and annoying to keep saying “Ankle Orthosis”, the term is commonly shortened to the abbreviation “AFO” (which stands for Ankle, Foot Orthosis).

AFOs can be described as the “bread and butter” of the orthotic industry. They are by far the most common type of orthosis. The AFO category is broad and varied. This makes sense because there is a wide variety of people who need AFOs for many different reasons. My next few posts are going to talk some more about AFOs. Upcoming topics to include:  some of the most common reasons people would need an AFO, types of AFOs, and the history and future of AFOs. I have already started to scratch the surface of this topic in these previous blogs: https://walkwellstaywell.wordpress.com/2013/10/20/creative-problem-solving/   https://walkwellstaywell.wordpress.com/2013/09/22/lace-up-ankle-braces/ . But it’s a big topic and there is plenty more to say on the subject. Stay tuned for more info!

Walk Well

Custom foot orthotics.

Shame on me. I realized that I have been writing this blog for a little over 2 years and I have never once taken the time to show you how I make custom foot orthotics. It’s only the number one thing that I do. I am going to correct that error right now.

In my opinion, foot orthotics are very often the most successful and un-invasive way to correct bad body alignment, allowing patients to recover from and prevent many kinds of overuse injuries.  Custom foot orthotics are made from scratch for each individual patient. The materials and techniques used to make foot orthotics can vary widely depending on the needs of the patient and the skills of the practitioner.

I am going to walk you through the step-by-step process. The pictures in this blog are just snap-shots I took while at work one day – sorry for the low quality.

Step 1:  Take a mold of the patient’s foot.

BioFoam molds

BioFoam molds

This mold is a box full of crushable foam into which the patient’s foot has been pressed. Another type of mold is made from plaster casting material which is wrapped around the foot (See below).

Plaster cast

Plaster cast

This plaster type of mold is messier and takes a little longer, so it is usually only used for more complicated cases.

Step 2: Make a replica of the patient’s foot

Plaster is poured into the footprint or plaster mold and allowed to harden into the shape of the patient’s foot. It is removed from the mold and cleaned up to smooth out all the rough edges. When it is ready it looks like this:

Model of Patient's Foot

Model of Patient’s Foot

Step 3: Mold material to the model of the foot

The material that foot orthotics are made from comes in large flat sheets of various thicknesses. A blank of suitable material is cut to fit the patient’s foot size.

Cut out a blank

Cut out a blank

Next, the material is heated in an oven until it becomes soft and pliable. The model of the patient’s foot is placed in a vacuum press which will be used to shape the material around the plaster cast. The hot material is removed from the oven and draped over the cast while a powerful vacuum suctions the rubber membrane of the press against the model. There are no pictures of this step because it is so time sensitive that I couldn’t do it one-handed.

This is a picture of the model of the patient’s foot inside of the vacuum press with the hot material being molded to it. I am using my thumb to smooth out any air bubbles that form underneath the rubber to ensure a good mold.

In the Vacuum Press

In the Vacuum Press

Step 4: Finalizing the Orthotic

Once the material has finished cooling in the vacuum press it can be trimmed down to its final shape. The molding process has created wrinkles and left excess material that has to be removed. Here is what it looks like when I take it out of the press.

After the Vacuum Press

After the Vacuum Press

Posterior View After Vacuum Press

Posterior View After Vacuum Press

At this point, the sides of the orthotic material wrap around the mold too far and would create a lot of unnecessary bulk inside the patient’s shoe. It is trimmed down with the use of a grinder. Sorry, there are no pictures of me using the grinder for what I hope are obvious safety-related reasons.

Once it has been ground down it looks like this:

Side View After Trimming

Side View After Trimming

See how the material exactly matches the contour of the patient’s arch?

Here is a view from the heel:

From the heel

From the heel

Step 5: Fit the orthotic to the patient.

At this point, the patient returns to the office with a pair of appropriate shoes. The final touches are added to the orthotic while the patient is present. This might include attaching a full-length top cover or grinding off additional material to tailor the orthotic exactly to the patient’s needs. It is very important for the practitioner (that’s me) to watch the patient walk with his or her new foot orthotics. This ensures that the foot orthotic can be properly adjusted to the patient’s individual needs. It pays to be very picky at this point. The patient should be able to give feed-back as to how the orthotics feel underfoot. And the practitioner should be able to see a marked improvement in the way the patient is walking. In my office, the patient doesn’t leave their fitting appointment until we are both satisfied that the orthotics are the best they can be.

Things you should know:

Custom foot orthotics are great when they are made well, but they can also be pure torture to the patient if they are made incorrectly. It is a big responsibility. Many offices do not make their foot orthotics themselves; instead, they send all foot orthotic molds out to a central fabrication facility. This means that every time the patient requires some sort of adjustment the orthotics have to be sent back to the fabrication lab. This can be costly, frustrating and time-consuming. I recommend to all patients that if they have complicated foot issues they should get their foot orthotics from someone who makes them in-house.

One other thing to be cautious of is to make sure that if you are paying for custom foot orthotics – they actually are custom foot orthotics. Look back at step 1. If you don’t have a mold of some sort taken of your feet, then you should decline treatment and go somewhere else. FYI: There are some facilities that use a 3D scanner to capture the shape of your feet – this is sort of like taking a mold, it is acceptable. **Note: The little electronic platform that some stores have you stand on only shows the high pressure areas of your feet and does not count as a mold-taking process.** That is just technologically advanced smoke and mirrors. Don’t be too impressed.

My advice is to do your research before you buy any type of foot orthotic. Know how much they cost. If you are wondering, the industry average for a pair of custom made foot orthotics is in the neighborhood of $400. Most insurances do not cover the cost of foot orthotics. For this reason, many people try to purchase off-the-shelf foot orthotics to save money. Sometimes this works. Actually, if you have a pretty average foot shape and your problems aren’t too severe – then I say go ahead and try it. But, if you have unusual feet then I can already tell you that it isn’t going to work.

Here is a picture of that same patient’s foot mold sitting on top of an off-the-shelf foot orthotic:

Off-the Shelf = Poor fit

Off-the Shelf = Poor fit

And just for comparison, here again is the newly made custom orthotic for the same foot:

Side View to show arch contour

Side view to show arch shape

See what’s going on here? All that gaping between the patient’s arch and the prefabricated foot orthotic means that the foot will not be getting enough support. Whereas the custom foot orthotic follows the arch of the foot exactly, supporting it evenly and completely. That support can be the difference between sore feet and happy feet.

Well, that concludes this little back-stage glimpse into the magic that happens in an orthotic lab. I hope you have enjoyed it! If you have any questions, feel free to comment below and I will do my best to clear things up for you.

Walk Well!

Creative problem solving

My grandpa fell in love with my grandma because of her creativity. They were in college and they both were attending a dance in a lodge with a fireplace. As soon as the fire was lit, the room began to fill with smoke. Grandpa climbed up on the mantle to investigate the problem and found that the flue wasn’t staying open. He called down into the crowd saying he was sure he could fix the issue if only someone would bring him some string. Soon a girl (Grandma) came over with a small length of white rope. “Will this do?” He saw that it was a string from a mop and he laughed.  It did the trick. He fixed the flue, they danced the night away and the rest is history.

I get really excited about creativity. I guess you could say it’s in my blood. I especially admire innovative problem solving. Albert Einstien famously said: “The definition of insanity is doing the same thing over and over and expecting different results”.

When I think about this quote I remember something that I watched happen while I was on a mission’s trip in the Dominican Republic. Our group was doing some demolition and construction work. Part of this involved using sledge hammers to break up an old cement staircase. We had some big strong guys in our group who were confident that they could handle the job. The biggest guy grabbed the heaviest hammer and swung it as hard as he could. It bounced off the cement without even making a dent. He swung again and again with only blisters on his hands to show for all the effort. Our translator, who was just a skinny little guy, shook his head when he saw what our strong men were doing and picked up a hammer to show how it was supposed to be done. He took one swing and chipped a huge piece off the edge of the top step, he took another and an even bigger chunk cracked away. He explained that cement is resistant to direct blows but if you hit it at an angle it becomes fragile.

I remember this every time I come up against a big obstacle. If at first you don’t succeed…Try the periphery. Walk the borders and look for another way in. Use glancing blows. Harness your creativity. This is what problem solving is all about.

I chose to work in the discipline of Orthotics for several reasons, but one of them was because I saw that it had problems that needed solving. In my undergraduate arrogance I was sure that I could fix the field singlehandedly. I couldn’t wait to get started. Now that I’m actually working in the profession I can still see those flaws, but they seem bigger and more complicated up close. One of the most challenging aspects of the field is its inertia. It’s a lot like an old decrepit concrete staircase that has been sitting around unchanged for the last 50 years.

Here’s an example: Below are 2 pictures of AFOs (Which stands for Ankle Foot Orthosis, “orthosis” means “brace”).  The type of metal brace pictured has been around since the Civil War, and believe it or not, people still wear them today. Can you imagine if all medical technology had not advanced since the Civil War days? We would still be performing operations with rusty old saws and dying from infections without the use of antibiotics. To be fair, that type of AFO is now referred to as the “old style” but “old style” in the same way that bellbottom pants are old style…they are still acceptable, just not considered cutting edge.

old AFO

pic from: http://www.orthomedics.us/Pages/ankle.aspx

The “New style” AFOs are made out of plastic. This type of AFO began to be used in the late 1960’s -1970s, and it really hasn’t changed since. Once again, just for a little perspective – Star Trek was a hit show when this type of brace was developed…to a young person like me this is ancient history. In the last 5 years the Orthotic industry has started to think about possibly accepting the computer fabrication, 3D printing and CAD CAM methods of making braces. But with characteristic glacial slowness, acceptance of this advanced technology hasn’t become very widespread.

Plastic AFO

Pic from: http://www.georgelianmd.com/cms/InformationLinks/Braces/tabid/124/Default.aspx

There are, of course, multiple reasons for how “stuck in a rut” the Orthotic field is. For one thing, only a few orthotic training programs exist in the country, and those are run by the old-school practitioners who continue to teach the “time tested” methods of brace making. For another thing, insurance companies use a series of L-Codes to categorize braces and determine how much money they are willing to pay for each type of brace. These L-codes were set up in the same Star Trek, bellbottom era as the plastic AFOs, and the system is limited largely to what was available back then. Practitioners can’t afford to make newer, more elaborate braces if they are still going to get paid 1970’s prices for their work. And that’s just the beginning of the reasons for the profession’s retarded development.

Realizing all of this has been a little daunting. I don’t think I will be able to wave my magic wand and fix this profession as quickly as I had planned. It’s going to take some work. I’m going to have to continue to swing my sledge hammer at the edges of the problem. Fortunately I am young and patient. The demographics of the Orthotics profession is changing, more young people like me are joining up. I hope they bring their creativity with them.

I have plans to pursue a PhD in the near future. This will allow me to do research in and around the Orthotics field. I can study the old methods and think of new solutions. There is only one problem…I’m going to have to be creative about finding a research institution that will equip me with the knowledge and skills I need to move forward. (In case you hadn’t guessed, I can’t exactly find a university with a graduate program tailor-made for problem solving within the Orthotic industry…try googling that. Nothing.)  It’s just another barrier to negotiate around. (Seriously, if you have suggestions on grad schools let me know.) Collaboration and an interdisciplinary approach is the key.

Some people are already coming up with creative solutions. Check out this website:

http://www.silverringsplint.com/about/

Here’s an example of someone taking an old clunky style brace like this:

Clunky finger splint

And making it into something modern and beautiful and functional like this:

Cool ring splint

That’s creative genius. That’s what I’m talking about.

It’s innovation like this that gets me fired up. We need to take the same imaginative problem solving into the rest of Orthotics. This is important, because if we don’t change our profession we will just continue on in the status quo. Extinct like the dinosaurs. Stuck in a time warp. Doing the same thing over and over again. How insane would that be?

Walk well (and think creatively!).

Lace-up Ankle Braces

The most common type of brace worn is the ankle brace. There are hundreds of varieties of ankle bracing systems in existence…I will probably discuss them all eventually, but today we are going basic.

Very basic.

Right back to the beginning.

When an ankle has been injured, the treatment is to wrap something around it in order to support the joint, give compression to reduce swelling and limit motion. This treatment has been around since the first Egyptian bound some strips of linen around his sandal after he tripped over a rock. (No, really – they have found picture evidence of ancient splinting mixed in with the hieroglyphics in some pharaoh’s tomb).

The truth is, this treatment technology hasn’t really changed much over the years. Modern day athletes have their weak or injured ankles taped by Athletic Trainers. The cloth tape supports the ankle and reinforces it, restricting ankle movement in an attempt to reduce pain and risk of re-injury. This works really well for athletes who have a staff of Athletic Trainers to take care of them. But there are a lot situations when ankle taping is impractical. For example; If the injury is going to need long-term treatment, or if the person does not have access to someone who can tape their ankles. Lace-up ankle braces work very well to approximate the same type of support you would get from a tape job.

The most famous brand of lace-up ankle brace is the Swede-o brace. It looks like this:

If the basic Swede-o brace doesn’t provide enough support for you, I recommend the ASO brace (or something with a similar concept). This type of brace has extra straps that can be wrapped around the ankle to add an additional level of stabilization.

These two types of ankle brace are sturdy, low profile and functional. They fit easily into athletic shoes and can be worn while playing sports or during everyday activities.  One draw-back of a lace-up style ankle brace is that it usually takes a bit of time to put them on, what with all the ties and straps.

Both the ASO style and the plain lace-up style ankle braces contain small removable plastic stays on either side of the ankle. When worn with a well-laced shoe the combination of tough fabric and thin pieces of plastic in these braces provide enough stiffness to support most ankles.

ASO stay Swedo stay

Notice I said “most ankles”. I probably should have said “average ankles”. Because as we all know, there are always those people who are not and never will be average. In this case I’m talking about people who either have really whacky ankle alignment or who are in need of serious, big league motion control. But never fear, the lace-up ankle brace category has a big brother…literally. The Arizona brace.

The Arizona brace works on the same principles as the other lace-up braces, just multiply everything by 10. Instead of small, removable plastic stays, the Arizona has a solid plastic core that is custom molded to fit the patient’s ankle. That’s right. I said custom molded. And because you can’t drape molten plastic over someone’s leg (well, you can – but it is very much not advisable) you have to take a cast of their leg and make a model from that cast and then you can make the brace. Yeah. It’s complicated. I’m sure I will write a blog post about the custom brace making process one of these days. For now, all you need to know is that it takes a lot of skilled labor to make a custom brace.  And skilled labor = $$$$.

Arizona braces are very expensive. But they are tough and strong and boy do they work. The traditional style Arizona braces have a leather covering over the plastic that allows the brace to be laced up like a logging boot or an ice-skate. The Arizona brace is a bit bulky but most people can still fit it into their regular shoes.  Because leather is pretty old-tech and can get gross and smelly, some companies have started making Arizona-style braces out of all synthetic materials. I think this is the way to go. Here’s a picture of what that looks like, in case you are curious.

Now, it’s not all flowers and butterflies with a lace-up style ankle brace. There are some other things that have to be considered. The Arizona brace pretty much renders the ankle immovable. It’s like an ankle fusion without the surgery. Even the wimpier over-the counter lace-up braces limit the up and down movements of the foot and ankle.

Locking up the ankle can be a bad thing. After all, it was designed to move for a reason. For one thing, the ankle adapts to the angles of uneven terrain to make walking easier. Ankle movement also allows the foot to absorb shock with every step. If this doesn’t happen, the jolt of each footfall is transmitted up the leg until it effects the knees, hips and back. This is why everybody should be sure to have just the right amount of support for their own personal needs. Over-bracing is not a good idea. And that’s coming from someone who makes and sells braces for a living.

So if you are a lace-up ankle brace wearer, do a couple of things for yourself:

–          Talk to a physical therapist (or someone like that) who can give you some ankle strengthening exercises to do. Maybe you can eventually phase out of your brace wearing, or at least step down to a less-restrictive style.

–          Wear your brace when you need it, and don’t wear it when you don’t. This will ensure that your brace lasts longer and that the little stabilizing muscles in your foot and ankle don’t forget how to do their job.

–          Do your homework. Make sure you are wearing the best brace for you.  At the very least do a google search.  You are in charge of your own treatment….just like that Egyptian guy who first wrapped a rag around his ankle. Aaannnd we come full circle.

Walk well!

Suspension

Lately I’ve been fitting a lot of knee braces. Something about the summer time seems to prompt people to jump off things, ride their bicycles too fast and rollerblade on uneven surfaces. When their stunts go awry, these people come to see me to get fit for a brace.

Knee braces come in all shapes and sizes. Here are some examples:

If the patient is going to have knee surgery (such as to repair some torn ligaments) they will be fit with a brace that looks something like this:

If they need continued support after surgery and rehabilitation they may be assigned a functional brace something along these lines:

If the injury is not bad enough to need surgery but the patient has general soreness and swelling they will probably be given this sort of brace.

I will write a more detailed post another time about the function of each type of knee brace, but right now I want to focus on something that they all have in common. In order for a knee brace to work, it has to stay in the right place. It is really hard to keep a knee brace in the proper position. This is a problem that I never encountered with foot orthotics. You see, foot orthotics stay in place because you stand on top of them. Not so with knee braces. Good old gravity works against even the best brace and tries to pull it down.

In the orthotics world we call the ability of a brace to stay in the right place suspension. This is why knee braces have so many straps.  We are trying to suspend the brace above the ground by anchoring it firmly against the leg.

Gravity is only half the problem however. Most people have conical legs. That is to say, the circumference of their thigh is greater than the circumference of their calf. Think of the shape of an upside-down traffic cone.

conical legs

Now think this through with me – Let’s say your leg is shaped like that. Even if you were to tighten the straps on your brace down really hard, what is to keep the whole thing from sliding south? Not much. In fact, there is only 1 thing that stops the brace from migrating down around your ankles. It is called the Gastrocnemius and is definitely in my top 10 list of the coolest muscles in the body.

gastroc

The Gastrocnemius forms a little “shelf” in the back of the calf where the leg is a little bit skinnier just below the knee. This is the place to win the fight against gravity. In order for a knee brace to be suspended effectively it has to grab onto the leg right here. If you look back at the three types of knee braces at the top of this blog, you can see that each model has a strap in this spot. That is no coincidence.

brace stapping

Many knee brace wearers don’t understand this fact. People often over-tighten the straps of their brace and then they just have a really uncomfortable knee brace that still feels like it is going to fall off. This leads to skin irritation and rubbing and general miserableness that causes people to abandon their braces. Knee braces are only effective if they are actually worn. And worn correctly I might add.

If you are a knee brace wearer, don’t let gravity get the better of you. Harness the power of your Gastrocnemius and keep that brace suspended.

Also, enjoy the last of this warm summer weather and try not to hurt yourself doing anything stupid.

Walk well!

More Letters… Nbd…

Two weekends ago I took my Orthotic Fitter Certification test. It took place in a computer testing center in a bank in Rochester NY. Other than the 2 of us taking tests and person administrating the exams the bank was empty and quiet on a Saturday afternoon. The other test taker was on her second attempt at some sort of counseling/ mental health examination. The test administrator asked me what in the world an Orthotic Fitter was. I gave her a brief explanation and she still looked puzzled. After the other test taker and I checked all our belongings into a locked cabinet, We were issued pieces of scrap paper and 2 pencils each and then marched into a tiny cubical of a room with cameras pointing at us from every angle.

I smiled at the camera over my computer monitor, clicked OK, and it took a dorky looking picture of me which was then posted to the top Right corner of the screen. Great. Then I had to answer a bunch of strangely worded multiple choice questions that were designed to trick me into answering incorrectly. Somewhere around question 75 I thought to myself that this sort of exam is really testing to see if you are good at test taking, not necessarily if you thoroughly understand your subject matter. Oh well.

I stuck to my usual test taking strategy, blowing through the easy questions quickly and then going back through to check my work and puzzle about the harder ones. I hadn’t really studied for this test like I usually do, it was hard because the subject matter was broad; how to brace any part of the body for any possible injury. How do you even study for that? I had settled for reading back through my notes from the Orthotic Fitter class I attended and flipping through an old text book that my boss lent me from his days in Orthotist School.

Thankfully I was able to piece together all this info and answer most of the questions without much trouble. After I was sure I had done my best I clicked the STOP button, waved good luck to my fellow test taker and walked out into the hallway. As I exited the room I could hear a little printer on top of the locked cabinet whirring. It spit out a single piece of paper and the test administrator picked it up. She glanced at it before giving it me, said “congratulations” and handed me my purse from inside the cabinet. That was it. Another test over with. No big deal.  Another certification under my belt. A couple more letters behind my name. (Now it is officially Angela Smalley MS, CES, BOCPD, COF).

Now I’m a Certified Orthotic Fitter, which means I can fit any type of prefabricated braces for any part of the body. Yay! So the shape and focus of this blog may change a little now. You might see me writing about knee injuries or elbow braces. But don’t worry. I won’t forget Pedorthics.

Walk well.

P.S. Sorry for the lack of pictures…Here is a link to the BOC’s website explaining what an Orthotic Fitter is in case you are interested:

http://www.bocusa.org/orthotic-fitter-certification-cof

UCBLs / Captive audience

Well, the long awaited laptop has arrived. I can now happily multitask again, reading some nerdy article while typing away in a Word document AT THE SAME TIME! I didn’t think this was a big deal until I couldn’t do it anymore. I tell ya, there are some things an Ipad just won’t do.

Anyway, today’s topic is UCBL style foot orthotics. For the past few weeks I’ve been making them like they are going out of style. The term UCBL stands for University of California Berkley Labs, where the UCBL was first developed.

There is a bit of a debate about what constitutes a UCBL foot orthotic. The definition is shaky. People market a wide variety of foot orthotics as UCBLs. Here are some pictures to give you an idea:

UCBLs

The general consensus is that a UCBL foot orthotic is made out of a rigid material such as plastic or carbon fiber. It is usually molded to a model of the patient’s foot (but it is possible to purchase prefabricated UCBLs). The side of the UCBL are deep, cupping the heel and extending up around the edges of the foot. The UCBL usually ends just before the Metatarsal Heads of the foot. See the green lines in the picture below.

UCBL trimlines
The purpose of a UCBL foot orthotic is to control and aggressively correct the foot. UCBLs are most often used for people who pronate severely, often because of flexible flat foot (also called Pes Planus) or because their Posterior Tibial Tendon is ruptured or damaged.

FlatFoot-Figure-2
UCBLs are usually prescribed when nothing else will work. They are bulky and hard to fit into shoes. I’ve been told that they are an absolute bear to break in. They are hard and unforgiving and have to be made absolutely right otherwise they will cause rubbing and blisters and skin irritation. Speaking from a Pedorthist’s point of view, they are a pain in the neck to make.  So why haven’t UCBLs gone extinct with the dinosaur? And furthermore, why have I made so many of them in the past few weeks? Because if they are done right, they work wonders. UCBLs operate under what I like to call the “captive audience” premise.
Have you ever been at a social event and gotten cornered into talking to a really annoying person? You use sophisticated strategies to get out of the situation. At the first possible excuse you put some distance between yourself and the talker, then you rope some other innocent bystander into the conversation. Then you see someone across the room you have to run over and greet. Whew. Disaster averted.

Well, your feet do similar things. Sort of. If you have a really flat or collapsed arch and then you stick an orthotic with an  aggressive arch support underneath it, your foot is just going to slide off to the side in an effort to escape the uncomfortable situation. This leaves your shoes looking like this:

ripped out lateral side

And your arch is no better off than it was before.
A UCBL grabs both sides of your feet, holding your arch against the support with the help of your shoe. This forces your foot to adapt to the shape of the UCBL. Whether it likes it or not. To return to the awkward talker analogy – it’s as if the talker were seated next to you on a long airplane flight. You can’t get away!

talker

I warned you earlier that UCBLs are unpleasant to get used to. (Like an obnoxious conversationalist). But give them time, and your feet will adapt to the situation. If you had bad enough alignment to warrant needing a UCBL in the first place, you will begin to notice an improvement after wearing them for about 1 week. At the end of two weeks, you should be able to forget you are wearing them. And you should be able to see a positive change in the arch, ankle, knee and back pain that first prompted you to ask your doctor for a prescription for foot orthotics.

As for the annoying talker, I’m sorry – there’s nothing I can do about that. At least your feet won’t hurt while you are listening to his long winded story about his latest UFO conspiracy theory.

Picture sources:
http://www.delatorreop.com/orthotic-devices/all-devices/foot-orthotic-orthopedic-ucbl-220/
http://jmorthotics.com/products-childrens.php

http://www.footeducation.com/acquired-adult-flatfoot-deformity-posterior-tibial-tendon-dysfunction

http://www.thequadrastepsystem.com/ls.html

I’ve been tweeting!

Hi faithful blog readers…
I’m sorry it’s been such a long time since my last proper blog post. I have been laptop-less for the past 2 months, but a new one is on the way! Yay!

In the meantime, I’ve set up a Twitter account where I’m retweeting tons of relevant articles and videos about Pedorthics and sports medicine and the like. Check it out!

@walk_well

20130630-191330.jpg

The Sinus Tarsi

Due to circumstances beyond my control ( namely a laptop that grew legs and walked away in Atlanta last week) this is going to be a short blog.

I want to talk about the Sinus Tarsi because I think it is one of the more interesting landmarks of the foot and ankle.

Here’s a picture showing you the location of the Sinus Tarsi:

20130514-202432.jpg

Reach down and touch the ankle bone (Fibula) that sticks out on the outside (Lateral aspect) of your foot. Now slide your finger about an inch forward and down and you will feel your finger slide into a little depression. Congratulations, you just found your Sinus Tarsi (from now on known as ST – I’m getting tired of typing that….)

Before we go any further, I should explain that your ST isn’t really a thing. in fact, it is more of a lack of things than an actual structure itself. The anatomical term “Sinus” means some kind of hole or cavity in the body. The term “Tarsi” means pertaining to the tarsal bones. So the ST is just a gap between bones. Which doesn’t sound impressive, but it is actually a really important part of your foot and ankle.

I think of the Sinus Tarsi as the “Barometer” of the foot. If there is anything going wrong in a person’s foot, a quick check of the ST gives me some valuable clues.

Here is a more complete picture of what the ST looks like:

20130514-204155.jpg

As you can sort of see from my very low tech picture labeling, the ST falls between three very important bones of the foot: the Fibula, the Calcaneus and the Talus. These three bones slide and glide over each other in order to provide the movements of the ankle. If something is going to go wrong in the foot or ankle, this joint is going to be on the front lines of the battle. The ST also contains a couple of key blood vessels and some ligaments (Anterior Talofibular and Calcaneofibular) that provide stability to the ankle.

When I am evaluating a patient’s foot, I always check their ST right away. I put my thumb in there and push a little. What I am looking for is any pain or swelling. The ST is the perfect place for any small amount of swelling to hide. Someone’s ankle might not look swollen, but if their ST is filled with fluid, their ankle mechanics will be changed and they will have a feeling of stiffness or pain in their ankle. Everyone’s feet are a little different, so I check for swelling in the ST by comparing the sore ankle to the other side.

The ST is almost always swollen after an ankle sprain. But it can also collect fluid if the patient has a chronic foot or ankle issue. For instance, someone who pronates or supinates ( steps on the inside or the outside of their foot) often causes a bit of damage to the surface of their joints with every step. This damage adds up over time and causes a little bit of swelling to accumulate.

A swollen ST is a warning sign. It tells me that there is something wrong and I need to do a little detective work to find out what it is. That swelling will not go away until the issue is cleared up and the injury is healed.

Do you have swelling in your Sinus Tarsi? If so, you need to address the underlying problem. Did you sprain your ankle recently or do you think there is a problem with your foot alignment? Listen to your ST and get it checked out.

Walk well.

If you read my last post, you now know all about how a heel spur is formed. But what you still don’t know is what to do if you have one.  So let’s talk about treatment.

The most common treatment for heel spurs is to place a little squishy gel pad in your shoe. This is a good place to start – it can’t do any harm and it’s a pretty cheap fix. A word of advice: if you are going to bother putting a gel pad in your shoe, make it a heel cup not just a flat thing that sits under your foot. Here’s why:

You actually have a fat pad under your heel that was intended to provide cushion for your foot. (You can read all about it here ). The whole point of a heel cup is to contain that fat pad and push it back underneath your heel so that it can do its job.  Then on top of that, you get the additional cushioning provided by the actual material of the heel cup itself. If you just get a flat heel pad – then you don’t have the added benefit of using your body’s natural cushioning system, you only get the protection of that skimpy little piece of insole. And that is rarely enough.

Here are some of my favorite heel cups:

tuli heel cups

and

Mc D heel cups

Notice how they both have deep sides that really hug the heel? That’s what we are looking for. Not this:

crappy heel cups

Ok. Now that we’ve gotten that straightened out – we need to go a little deeper. Remember, I said that heel cups are the place to start. They are not the end all and be all of heel spur treatment.

One thing you have to understand is that heel spurs are not all that different from Plantar Fasciitis.

heel spurs and pump bumps

In fact, they are so closely related as to be almost indistinguishable.  The above picture was in my last post, it shows the areas where a heel spur can form.  Please notice that both locations are also the attachment sites of the Plantar Fascia and the Achilles Tendon. This means that pain in those areas could be from either the connective tissue itself or from the bone to which it attaches. But here’s the deal: it doesn’t really matter.  You are going to treat it exactly the same way. You need to eliminate the stress in the area and give it chance to heal.

1st you have to reduce the pulling stress:

Fascia tension

Pulling stresses occur when the attachment sites of tendons are under too much constant tension, this can cause little microscopic pieces of bone to be pulled off.  As you can imagine, your body does not appreciate this pulling stress and it decides to put a stop to it by reinforcing the area with extra bone – eventually forming a spur.

Eliminate pulling stress by stretching the muscles in the area. And I don’t mean stretching them once or twice, I mean that you have to stretch thoroughly and often in order to solve the problem.  Key areas to stretch include your Hamstrings, Gastrocnemius, Soleus and Plantar Fascia. (Read this blog post to get some stretching ideas)

2nd you must reduce the pounding stress:

Pounding stress is caused by too much blunt force trauma. Either you are using your feet too much on surfaces that are too hard…or…you weigh too much. Or sometimes a combination of both factors.

heel strike

The only way to reduce this type of stress is to either lessen the impact of each footstep or take fewer footsteps. Take a close look at how much work you are expecting your feet to do on a daily basis. If you are a heavy person or if you do a lot of high impact activity – you might have to drastically cut back.

3rd eliminate twisting stress.

If you are having heel pain, the chances are good that there is something wrong with the angle at which your heel contacts the ground. Maybe your heels roll out too much (Supination) or roll in too much (Pronation).  These extra motions mean that your heel has to twist as it strikes the ground, this causes excess stress in both the soft tissue and the bone surrounding the heel.

Supinated Pronated

Pronation or Supination could be the root of your problem. The best way to correct your foot alignment is with custom orthotics. Custom orthotics are made by Certified Pedorthists (like me, for example), Orthotists and Podiatrists.  They cost a lot of money, but they are worth it if you can’t kick your heel pain on your own.

foot-orthotic

If all else fails

Surgery is one solution that is sometimes promoted by podiatrists and orthopedic surgeons for the elimination of heel spurs. Well, that’s a pretty drastic measure – and I think that it is best to avoid it if at all possible. You see, surgery tends to lead to scar tissue (which is a lump of hardened, disorganized tissue that forms whenever soft tissue is operated on.) Scar tissue often leads to reduced flexibility and sock absorption in the damaged area. This in turn changes your biomechanics, causing your body to handle the stress of walking in a slightly different way than it usually would. This could cause increased pressure in those areas. Which could lead to…you guessed it, an overuse injury – like a bone spur. This is sometimes an example of the cure being worse than the disease. But just because I am not an advocate for surgery doesn’t mean it is always a bad idea. I’m just telling you to be sure to get a second opinion…and then a third…before you (proverbially) jump in with both feet.

Walk well!

Illustrations from:

http://www.walgreens.com/store/c/medi-dyne-heavy-duty-gel-heel-cup/ID=prod5874552-product

http://www.ortho-net.com/mcdavid/heel_cups-650.htm

http://www.theinsolestore.com/pedag-point-heel-spur-inserts.html

http://www.footsolutions.com/foot-problems

http://runningrules.com/run-like-a-fish-why-or-why-not-someone-might-want-to-change-their-shoes-or-style-of-running/

If I had a dollar for every patient who came to me complaining of “Heel Spurs” I would be rich.  Heel spurs are very commonly discussed and yet somehow they are very misunderstood. I’m going to try to shed some light on the matter:

First, I have to explain how any kind of bone spur forms, and for that we have to touch briefly on a law of the body called Wolf’s Law (one of these days I am going to devote a whole blog to Wolf’s Law…when I do, that link will be here).

To summarize quickly, Wolf’s Law states that the structures of our bodies adapt based on the types of stress to which we subject them. We think of our bones and cartilage as being a static structural framework that doesn’t change – but in actuality, our musculoskeletal system is being constantly remodeled and updated to accommodate our needs. Without delving into the technicalities, just think about it in the same way as your computer security software which is continually revising itself to deal with the most current threats to your system.

Windows-Updates-Available

What would you do if you were a volleyball player who kept banging your knees into the hard floor when you dove for the ball? Well, you would probably start wearing knee pads to protect yourself from bruises.

HC volleyball

But what if the soft, squishy knee pads weren’t enough protection for you? You would either stop being so hard on your knees or you would find some bigger, better, tougher knee padding.

Maybe something like this:

heavy duty knee pad

Or even this:

X heavy duty knee pad

Thrillingly enough, this is the same progression that your body goes through. If you repeatedly damage the same area, your body eventually decides that it is going to have to cushion that spot.  So it sends some fluid to the injury site (we call this swelling). This fluid response is intended to rush healing resources to the area and also to cushion the spot in order to prevent further damage. If at this point you notice a little bit of pain and swelling and you decide to stop whatever activity you were doing, then your body can usually deal with the problem and recover quickly.

Unfortunately, humans are stubborn.  We often don’t listen to this early warning signal and we just keep doing whatever it is that we were doing when the problem started. This moves us on to the next level. Just like the knee pads, we acquire bigger, tougher cushioning in the area of stress. This comes in the form of scar tissue. Thick, unorganized fibers of scar tissue cover the injury site in an effort to patch up the damage. This tissue is tough and not as flexible as the original structures. It protects by restricting motion. At this point you begin to notice that your joint is not working as well as used to – it feels stiff and sore and if you aren’t careful you can lose range of motion in the area.

If you ignore red flags # 1 and #2, there is still one last defense that your body can deploy to attempt to heal a repetitive injury zone. It can lay down extra layers of bone. Just like the hard shell on the last knee pad picture, your body forms a protective boney prominence to reinforce the structures that keep being damaged. This sounds like a good idea, and it works to a degree – but sometimes your body gets a little overzealous with the bone growth and you develop unwieldy lumps and bumps of bone in unfortunate places. These boney lumps are called bone spurs.

Bone spurs can occur anywhere in the body. But the ones we are talking about are in the heel of the foot. Hence the name Heel Spur. Most heel spurs are right in the bottom of the heel where the Plantar Fascia attaches. Many people form a type of bone spur on the back of their heels where the Achilles Tendon attaches.  These are sometimes called “Pump bumps”.

heel spurs and pump bumps

Now that we have gotten that much straight, I am going to give you the cliché message to “tune in next time to find out what happens”… In my next blog I will tell you about treatment options for heel spurs. In the meanwhile, if you think you are getting a heel spur – remember what I told you and stop doing damage to the area. Give it a rest!

Walk well.

Pictures “borrowed” from:

www.fixingaslowcomputer.com

http://athletics.houghton.edu/photo_gallery.aspx?gallery=4&path=wvball

www.wiggle.co.uk

www.aspen-international.com

First, do no harm.

Do those words sound familiar to you? They should – it’s a concept taken from the Hippocratic Oath. Hippocrates was a physician in ancient Greece. Among other things, he is famous for developing a standard of medical etiquette that has shaped the profession over the ages.  Most modern day physicians still say some sort of pledge to follow the principles of the Hippocratic Oath upon their graduation from medical school.

The actual phrase “First, do no harm” doesn’t necessarily appear in the modern day translations of the Oath.  You have to step back to the Latin versions to find the origin of this exact wording. Primum non nocere is the way it was written in Latin.  Nocere is the word for physically injuring a person, especially in the way that a criminal or a bully would beat up a victim.

hippo1

I think about this concept every day. In many ways, it may be what led me into the field of Pedorthics and Orthotics.  This is a profession that doesn’t get a lot of fanfare. I have mentioned in previous posts that I almost always have to explain my job to people – it’s not a well-recognized field. Leave it to me to pick the most obscure corner of the medical world to call my own.  The reason almost nobody has heard of Pedorthics and Orthotics is that we are, by definition, un-invasive.

My work comes down to this: all I am doing is preventing further harm – the patient’s body has to accomplish its own healing.  My job is to support, align and hold everything in place until the patient can recover from their injury.  I am not doing nothing, but I am doing as little as possible.  I’m not cutting anyone open, feeding anyone pills or injecting anyone with chemicals. I am just giving them something to wrap around, reinforce and rest upon.

hippo2

This month, I am working on adding an additional certification to my dossier. I will be taking a class to become a “Certified Orthotic Fitter”. Yeah, I know this is confusing since as a Pedorthist I already make and fit custom foot orthotics all the time. But this additional certification will allow me to fit braces and splints onto the entire body, not just the foot and ankle. I am excited about it. This will give me some more variety in my life. It will expand my scope of practice and give me the opportunity to help facilitate the healing of all kinds of injuries.

hippo3

Walk well!

Sources:

http://www.library.usyd.edu.au/libraries/rare/medicine/HippocratesAphorismi1736.jpg

http://www.ubortho.buffalo.edu/crooked.html

http://www.bocusa.org/orthotic-fitter-certification-cof

www.ossur.com

Pope’s Shoes

Pope Benedict XVI has stepped down from his role as head of the Catholic Church.  And speaking of stepping… just look at his shoes! Throughout his papacy, he has sported some pretty flashy kicks. I’m a Pedorthist (certified to fit shoes and make custom orthotics), so I am always looking at people’s footwear.

It never occurred to me to think about what kind of shoes a Pope wears until today.

It turns out that they wear RED SHOES! Isn’t that awesome?

red 1

So I immediately scoured the internet and dug up some info on the Pope’s shoes (keep in mind, I just found these facts online – they might not be infallible Gospel truth…little Biblical joke, get it?)

Here’s what I discovered:

–          Pope’s shoes have traditionally been made out of red leather. It’s a symbol of ruling power and possibly representative of martyr’s blood, St. Peter’s in particular. Red shoes are also worn by the Dalai Lama.

–          There are 2 kinds of shoes that a Pope wears: Papal Shoes and Papal Slippers. He wears the slippers indoors and to Mass. He wears the shoes when he is outdoors (which isn’t often…)

red 2

–          John Paul II, the previous Pope, chose not to wear the traditional red shoes most of the time. He chose plain old black or brown.

–          At one point, it was erroneously reported that Pope Benedict’s red shoes were made by Prada and many people were outraged by this extravagancy. But it turns out that they are hand crafted by a Peruvian Cordwainer (that’s the proper term form someone who makes shoes). The shoe maker’s name is Arellano; he came to Italy in the ‘90s and set up a shop near the Vatican.

red 3

–          Before Cardinal Joseph Ratzinger Aloisius became Pope Benedict XVI, he regularly took his shoes to Arellano’s shop to be repaired.  And that’s how it all started.

red 4

–          Now that Pope Benedict is no longer the Pope, he has to stop wearing his famous red slippers. He is trading them in for a plain brown pair of loafers that were given to him during his travels in Mexico last year.

Off topic, but interesting: the pope also is required to give up his official Twitter account and the protection of the Swiss Guard….I wonder what kind of shoes they wear…

–          Benedict’s shoes were so stylish that he was named “accessorizer of the year” in 2007 by Esquire magazine.

red 5

–          I wonder what kind of shoes the next Pope will wear? And if he needs orthotics will they be red also? Hmm…orthopedic papal footwear – there’s a concept for you.

To finish off, here is a funny clip about the Pope’s shoes. As you now will be able to recognize, it is entirely factually inaccurate. (And slightly irreverent…no disrespect intended, please nobody get riled up)

http://youtu.be/adsASJ43OT4

Walk well.

All info and pictures from:

http://worldnews.nbcnews.com/_news/2013/02/26/17100856-pope-to-wear-white-but-no-red-shoes-after-abdication?lite&ocid=msnhp&pos=2

http://en.wikipedia.org/wiki/Papal_shoes

http://www.theatlanticwire.com/global/2013/02/popes-new-shoes/62516/

http://www.washingtonpost.com/blogs/worldviews/wp/2013/02/26/the-story-of-pope-benedicts-infamous-red-shoes-which-he-will-give-up/

http://www.bing.com/images/search?q=pope%27s+shoes&FORM=IQFRBA&&id=21817B3D8EF211ECBC8E1AE2D20862496055B55F&selectedIndex=0#view=detail&id=21817B3D8EF211ECBC8E1AE2D20862496055B55F&selectedIndex=0

http://www.dieter-philippi.de/en/ecclesiastical-fineries/campagi-the-footgear-of-the-pope-and-the-clergy

%d bloggers like this: