Dirty hands

The internet is currently crammed with people talking about handwashing. This was something that we were all confident in our ability to do a few months ago, but suddenly there are videos demonstrating proper techniques and playlists of songs with 20 second choruses to hum to yourself to make sure you aren’t rushing the job. It’s important, and I glad that people are doing it…but, it has become just another thing to worry about.

 

I can offer you a simple antidote. Not to the virus (I wish!)… but at least to the cycle of obsessing about scrubbing away at an invisible threat with terminally dry skin being the only tangible result. My suggestion is to try some dirt-therapy. Here’s two examples of what that looks like for me:

Example 1): I’m an apartment-dweller these days. But I have a little back porch “garden” with a few flowerpots. Today was the day that I wanted to get it all out and ready for planting. Truth be told, there are still a few patches of snow on the ground up here in New England, so I will have a to wait a few more weeks to plant the seedlings. But I took advantage of a sunny afternoon to get set up. There was some…problem-solving involved. My porch only gets sunlight at one end and I wanted to maximize that area, so I had to devise a sort of railing-suspended double-decker plant pot arrangement. It involves a couple of plastic containers, a wire shelf that I found next to the dumpster last year, and some shoelaces. It is exactly as glamorous as it sounds.

I had only about 1/2 the potting soil that I needed, and I wasn’t about to risk the plague to go pay money for dirt, so I took a bucket and dug up some loamy soil from the woods. There followed about an extended session of hand-mixing that looked like a baking show gone wrong. It took me right back to childhood and it was surprisingly fun.

Example 2): The other messy thing I have been doing lately is pottery. This is not new, it is something I have done off and on for about 10 years. But this is the first time I have enjoyed the luxury of having my own pottery wheel in my own apartment. In January, I ordered a little wheel from the internet and turned a utility closet about the size of a phone booth into a tiny pottery studio.

Since then, I have been gradually getting back into throwing mugs and bowls. One of the funny things about making pottery in my own home “studio” (closet), is that I can get creative about what tools I use to shape the clay. The other day, I took a newly-made mug out into my kitchen and made a random pattern of dents on it by thumping it with the handle of a butter knife. I’m hoping that this will look charmingly artisan once the piece comes out of the kiln with glaze on it. It’s a risk. It could just look like someone didn’t know what they were doing. Only time will tell.

Anyway. That’s my suggestion for a little quarantine pick-me-up. Take a break from being so clean. I doubt that you will have to construct a double-decker porch garden or a closet pottery studio, but I am sure that there is something else that you can make or do. It only counts if it’s messy. Get up to your elbows in the kind of dirt that will get stuck under your fingernails. Change the oil in your car, build something in the workshop, bake some cookies, create a finger-painted masterpiece. When you are done, and you are scrubbing up at the sink, watch the cloudy water run down the drain. I’m sure that it will take you more than 20 seconds to get your hands clean and the whole time you will be thinking about how nice it was to fill your mind with something else for a while.

Stay well!

Life-space

It’s been a weird month. March is always kind of uncomfortable anyway, with winter dragging on and the mud season before spring. But COVID-19 has really distinguished March 2020 from all the rest. As the threat of the virus has escalated over the past weeks, strange stress-cracks began to show in our daily lives. Consider the unprecedented uptick in attention to toilet paper….pause to reflect on the fact that people who were thought to be unreasonable germaphobes now seem moderate and sensible…and take a minute to appreciate the introverts who have been training for voluntary social distancing all of their lives. 

I have been working from home this week and I realize what a privileged position I am in to be able to do so. My job (as a project leader for the TREAT Center at a medical device engineering firm called Simbex) consists of a lot of web meetings and phone calls with clients, and online research and writing. It is actually the perfect job to do remotely, so the transition has been pretty smooth. 

Yesterday, as I was taking my lunch break in my own kitchen (that part is still weird), I got an email from Dropbox saying that I needed to login to my account to keep it active. I haven’t really used that account since grad school, but I figured that there were some files I would want to keep, so I logged in. It was a trip down memory lane! Most of the files were related to my gig as a research assistant on a project focused on the community mobility of older adults. That project heavily referenced a concept called “life-space”, which is the theme of this post and is oddly poignant during this strange March. 

Life-space is a way to describe mobility (or, if you are an academic, you might call it a “conceptual framework”). There are five potential levels of life-space, shown in this image below. 

In normal circumstances, healthy, active people at Life-Space 5 essentially have no limitations on their mobility. They are free to go wherever they would like to go. In contrast, aging or disability reduces life-space in concentrically smaller circles until, at Life-Space 1, the person may be entirely confined to their home. 

Before this month, I would have said that I thoroughly understood the concept of life-space. I had observed it in my patients and elderly relatives, I had conducted Life-Space Assessments on study participants, I had written papers about it, I had even done a poster presentation about it in grad school.

But, as they say…”you don’t know what you’ve got till its gone”. This March, the concept of life-space limitations is playing out across society. A few months ago, Life-Space 5 seemed like business as usual. We could have flown anywhere and gone on any cruise we chose. Those were the days! As precautions are increasing and travel restrictions have been enacted, our life-spaces are shrinking and it chafes because we are used to such freedom. 

In my case, the daily commute has shrunk down from a 20-minute drive to the office and back, to a short walk across my apartment. I have spent about 40 hours this week sitting on the right hand side of my living room couch. I think this is more hours that I have sat on that couch since I got it last year. 

My daily walks have also subtly changed. I typically take a stroll around town in the evenings, usually passing a few fellow walkers on the trails and sidewalks. But now, the whole town is out walking their dogs, carefully staying more than 6 feet apart and shouting back and forth to each other, intentionally stretching their life-space as far as they can. Here is a picture taken of the sunset last night. It was pretty, but not spectacular. It probably wouldn’t have occurred to me to take that picture if I hadn’t been so focused on enjoying every moment out and about. 

It turns out that the coronavirus pandemic is the perfect opportunity to empathize with people who experience life-space limitations. In the months to come, I predict a bloom of new technologies to help overcome the limitations of proximity. This innovation will be a direct result of the temporary restrictions, but hopefully will have a lasting effect in improving quality of life for people who don’t have the luxury of unlimited mobility. I am looking forward to seeing what we all come up with. In the meantime, if you find yourself with time on your hands, and you want to read about life-space straight from the source, here is the link to the excellent 2005 research article by Dr. Claire Peel and colleagues at the University of Alabama at Birmingham.  https://academic.oup.com/ptj/article/85/10/1008/2804989

 

Now, more than ever – stay 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:

http://www.breg.com/products/knee-bracing/post-op/t-scope-post-op-post-operative-knee-brace

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

https://www.djoglobal.com/products/donjoy/legend

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.

http://www.bledsoebrace.com/products/crossover/

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.

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.

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.

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

The rest of the truth about heel spurs

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:

and

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

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.

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.

1^st you have to reduce the pulling stress:

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)

2^nd 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.

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.

3^rd 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.

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.

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/

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.

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.

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.

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

Serious cushion

Do you know about the minimalist footwear trend? I wrote about it near the end of this blog if you feel like doing some research.

But if you don’t, here is a quick summary: take as much substance as you can away from a running shoe, leaving only a thin sheet of rubber under your feet and some laces to tie it on with. And there you have it: minimalist footwear. These shoes are supposed to help you “get back to nature” and run “as close to barefoot as possible”. And it’s an idea that has caught on like a house on fire. I am not totally against the minimalist trend myself, but I do think it has its dangers. For example: when you sacrifice bulk in your running shoes, you also loose shock absorption.  Some people can get used to this type of set-up; those with perfect biomechanics can afford to let their feet hit the ground with little or no protection.

Not everyone is so lucky however. People who have extra body weight, poor alignment, or high mileage on difficult terrain, have to protect their joints. Sometimes minimalist footwear isn’t going to cut it. A lack of shock absorption under these circumstances can quickly lead to injury. These people need cushion, serious cushion.

A company named HOKA ONE ONE figured this out. More specifically, two shoe designers named Jean-Luc Diard and Nicolas Mermoud. These two guys decided to design a shoe that could reduce fatigue, impact and muscle strain in runners. The name HOKA is a Maori word that means something like “now is time to fly”. Their shoes are intended to be used for distance running, any length ranging from casual 5Ks to ultra-marathons.

 

The secret behind the success of HOKA ONE ONE, is the huge puffy midsoles. This allows the outsole to be about 50% larger than traditional running shoes. But somehow, the shoes remain light and nimble. The shoes are also designed to have a slight rocker sole to reduce the energy needed to toe off, at the same time, the flared sole provides excellent medial and lateral stability which reduces both pronation and supination tendencies at heel strike.

All good things, right? Right. HOKA ONE ONE is gaining popularity rapidly, especially with the die-hard, mega mileage crowd.  Those runners who tend to be susceptible to overuse injuries are among the brand’s biggest fans. I am a fan myself. Even though I hate running. I got the chance to try on a pair of these cool shoes this spring at the New England shoe show. I was impressed. In the short little jog I took around the convention center I could feel the difference in the shoe’s cushioning. When I took them off and slipped back into my own traditional-style trail runners I had the same disappointed and deflated feeling that you get when you walk on the ground after being on a trampoline for a while.

 

Now this blog entry isn’t just supposed to be an infomercial about the virtues of the HOKA ONE ONE brand. Think of this more as an FYI post. I just wanted you all to know that that “minimalist” is not your only option. For every culture there is a counter-culture. I think “maximalist” running shoes might just be the wave of the future – and I wanted to let you all know about it.

Of course, all of this coolness comes with a price. The going rate for a pair of HOKA ONE ONE running shoes is about $160. Which is kind of a lot. Even in the world of expensive running shoes. I think that if this design gains popularity, other brands will begin to mimic the technology and with any luck it will become more affordable.  The marshmallowy midsole is already being experimented with by at least one other brand for about $30 less.

So keep your eyes peeled. You might see this new trend popping up around you now that you are aware of it. Who knows, maybe you want to try it for yourself.  As a pedorthist, I get a little excited about the therapeutic possibilities of a shoe like this: what if I could use them for an injury recovery shoe? What about the uses for people with degenerative joint issues or arthritis or stress fractures? Wouldn’t those injuries benefit from reduced impact and improved shock absorption? Nobody knows for sure. The technology isn’t old enough to have been thoroughly tested.  But it is innovation and that is exciting…at least to shoe geeks like me.

Walk well.

All pictures and facts from HOKA ONE ONE official website:

http://hokaoneone-na.com/index.html

Well-Worn Paths: Explaining Muscle Memory

Last post I talked about how muscle memory helped me recall my ceramics and track skills even after not practicing either of them for more than a year. But I didn’t really talk about the mechanics of muscle memory – so I figured I better explain it. Here it goes:

You’ve heard of nerves, right?

Think of your nervous system as a series of pathways that allow signals to be carried to each of your muscle groups.

These neural paths run from your brain to your spinal cord and from there into every part of your body.  In areas that get a lot of use, your body constructs an infrastructure that will allow tons of signals to pass through. Like in a city, the major highways handle most of traffic. The exits of the highway funnel into various sections of the town, smaller roads lead to side streets, driveways and sidewalks.

 

The paths branch off into smaller and smaller sections until they reach more and more obscure destinations.  Each time you build a new skill, you construct another “road” that leads to a specific group of muscle fibers.

The more frequently you perform the actions, the more firmly established these walkways become.

Our bodies are smart and they begin to adapt to patterns of movement. If certain motions are repeated frequently, small “shortcuts” are formed that allow for the involved muscles to be fired more efficiently. This collection of short-cuts is what muscle memories are made of.

Just like a short-cut path in real life, muscle memories fade if we don’t use them – but traces of the movement patterns remain and they are fairly easy to revive again once we put them back into action.

Usually we think of muscle memories as a good thing, because they help us perform specialized tasks with ease after we practice for a while. But, as I mentioned before, there can be some negative consequences to muscle memory.

For instance, say you are someone who has a Pathological Movement Pattern. “Oh no!” you say, “Not a pathological movement pattern, say it ain’t so!” Yes. It’s so.

A pathological movement pattern is a series of actions that you perform regularly, but you don’t do it properly – so you are actually causing some sort of harm to yourself. A good example of this is someone who has always pronated severely while walking. The pronated foot position has changed the movement of the entire leg and by extension, the rest of the body. Because this motion has been performed for so long, the muscles are used to moving that way; they have established very deeply engrained pathways to support that movement.  This means that they are going to be very hard to fix.

It takes a lot of time and effort to erase muscle memories, and the longer you allow yourself to move incorrectly, the harder it will be. This is why exercise is serious business. Every movement you make is a part of your permanent record. If you get into the routine of doing things incorrectly, you will begin to build bad habits and soon you will develop muscular imbalances.  Muscular imbalances lead to overuse injuries.

Take this as a warning.  Don’t let yourself get stuck in a rut (get, it – like a worn path…)

 

 

Exercise correctly (both stretching and strengthening), practice good posture, and wear supportive shoes. Body alignment matters. You don’t want to have to erase bad muscle memories.

Next time, we will talk about the concept of training/ retraining muscle groups to harness the power of muscle memory for good.

Walk well.

Pictures from:

http://upload.wikimedia.org/wikipedia/commons/b/ba/Nervous_system_diagram.png

http://www.johnlund.com/images/JL-interchange__2FG.jpg

http://2.bp.blogspot.com/_IZ1wip6Y4vk/S-reArjjaWI/AAAAAAAAArU/ZVG0h3MRe7k/s1600/small_town_street_R.jpg

http://upload.wikimedia.org/wikipedia/commons/0/07/Old_road_to_Nab_End_Quarries_(now_disused)_-_geograph.org.uk_-_1251202.jpg

http://blog.lenovo.com/images/legacy/files/2011/02/path-shortcut.jpg

http://hobbledrunner.blogspot.com/2012/04/hey-you.html

Practice Makes Perfect: an old dinosaur remembers.

I have been back in my hometown for the last few weeks, and it’s weird. I told my Dad that I feel like a dinosaur that lived a little too long after the ice age – the scenery is familiar, but a lot of my friends have left…This is a little college town and I graduated two and half years ago, so I recognize only the upper classmen on campus. But, thankfully, there are some things that haven’t changed. My best friends that I grew up with are still here, my family is here, and I love being home.

These weeks at home have given me opportunity to re-engage in two of my favorite activities; Ceramics and Track and Field. I know…weird combination? Yes. But hold on, there is a common denominator here.

Throwing on a pottery wheel is one of my favorite activities ever. It is messy, meditative, and addicting. I love it. I can make a bowl or a mug or plate or a jar or a vase out of a lump of mud and some centrifugal force.  I was a little bit afraid that I had forgotten how to throw because I hadn’t done it in a year. But after a couple of tries, my hands began remember what to do.  I was soon feeling comfortable with the clay again and I could relax into making things without having to think about my every move.

Quick clip of a guy who really knows what he is doing on the potter’s wheel:

Also, I have been working with the Track and Field team at the College. I used to be a Javelin and Hammer thrower while I was a student and an assistant track coach while at grad school.  This is another highly specialized activity that I haven’t done in a year. I was actually really nervous the first day I went to practice. I had almost forgotten how to visualize the throwing techniques, how was I going to be able to coach anyone? But it happened again: I walked into the throwing area and it all came back to me. I was able to demonstrate turns and pick apart throws and give some pointers to the athletes.

Some of the best hammer throwing your will ever see

What is that helps your body to remember how to do things after so much time? It’s called Muscle Memory and it is going to be the subject of my next few blog posts. Each person has a “vocabulary” of thousands of actions that they perform on a daily basis. You can brush your teeth easily, without even thinking about it because it is something that you do every day (I hope).  But do you remember the day you first began to learn an instrument? Each finger position had to be described to you, your movements were slow and halting because you had never done them before. It took months of practice before you could just sit down and play.

That word “practice” is the key to muscle memory. Repetition cements certain actions into our repertoire of movements.  I was able to remember how to make pottery and how to throw the hammer because I had spent endless hours engaged in those activities in the past. They had become second nature to me.  And after a little initial rustiness, my muscle memories were quickly refreshed.

A little bowl from last week’s work

One more thing, although muscle memory is usually a positive thing, it does have a dark side. Dun Dun DUNNN!!! (That was the text version of dramatic music). We will talk about it next time – along with a few tips on how to build the right muscle memories so that your body can perform at its top potential.

Until then, walk well.

Big Fat Truth: The OSFS Cycle, Good Hair and Lucky Socks

I debated about writing this blog, because it is an awkward topic. I halfway wrote a nice, inoffensive essay about comparing and contrasting the effects of taping versus bracing during injury rehab. But it was boring – I was bored writing it, and I figured nobody would want to read it. So here it goes: a blog about the problems with being overweight. If that doesn’t get you fired up, you’ve never had a cheeseburger.

I have so many patients who whisper to me during their evaluation, “I know I could stand to lose a little weight and that is not helping things…” And then in the next breath they say to me, “but my feet hurt so much that I can’t exercise…” These people are stuck in what I like to call the OSFS (Overweight, Sore Feet, Sedentary) cycle:

Like any good theory, this one has its merits. It’s a little bit true.

– If you are overweight, you will be putting more pressure on your feet with every step.

– If your feet are sore, you will be more likely to take fewer steps.

– If you take fewer steps, you are more likely to become overweight.

But here is another truth you have to keep in mind:

Correlation ≠ Causation

In other words – just because you notice that two things occur together, it does not necessarily mean that one event was triggered by the other. Here is a silly example, “whenever I wear my lucky socks I have a good hair day, therefore if I want to have a good hair day- all I have to do is wear my lucky socks.”

We laugh at this logic because we can clearly see that it is full of holes. But I think it is an important reminder to be sure that we are not making assumptions about other events in our lives.

It would be convenient if the OSFS cycle were always true. Then we would know exactly what to do to solve the problem. Just fix the sore feet and people would magically start exercising and lose weight and live happily ever after. But clearly, this does not always work. If it did, I would be in danger of working myself out of a job.

Here are some reasons that I know the OSFS cycle is not the complete picture:

– Even skinny people have sore feet

– Not all overweight people have foot problems

– Lastly (and unfortunately), when I fix someone’s feet, they do not necessarily begin exercising.

The truth is, there are myriad reasons for both sore feet and for obesity. The two conditions often occur together, and even usually contribute to one another, but I don’t think it is fair to blame one on the other.

I read an article (see link below) about how people who need knee or hip replacements often tell their doctor that they can’t wait until they feel better so that they can start exercising and lose weight. But the disturbing reality is, even after successful surgery, up to 75% of the patients gained weight in the next three years. Instead of getting healthier, these patients just continued on in their current trajectory. Only now, they didn’t have the excuse of a painful medical condition keeping them from exercise.

You may be wondering why I am bringing up this uncomfortable truth. Because, frankly, I am hoping that people read it and feel guilty. But, just in case guilt is not a powerful enough motivator, here are some other things to think about if you are overweight and you have sore feet:

– The 26 bones in your feet flex and move as you put weight on them. If you are too heavy, you are like an oversized load driving on a suspension bridge – the chances are good that you are eventually going to do some permanent damage to the support structures.

– Pedorthist like me can design orthotics to help your sore feet, but if you are overweight you significantly reduce our options of materials and techniques that we can use. We have to employ heavy duty materials that will resist the amount of force you put on them with each step. These adaptations mean that your orthotics will be bulkier and less comfortable.

– You are going to wear out your shoes and orthotics much more quickly. This is going to create additional expense and inconvenience; you may have to buy new shoes as frequently as every 2-3 months. You will need more orthotic adjustment appointments. All this takes more time and more money than would be needed to treat a patient who is not overweight.

– Patients who are overweight have a much lower success rate when it comes to orthotic treatment. They are also much more likely to develop complications such as pressure sores or blisters. These risk factors can discourage practitioners from using aggressive correction techniques. This often means that instead of correcting your underlying alignment problem, your orthotics might just be providing cushioning so that you can be comfortable.

All this to say, don’t use the OSFS cycle as your excuse. If your feet hurt, go get them checked out. Buy some supportive shoes and some orthotics if you need them and then get out and use them. What are you waiting for? If you wait until you are totally free of aches and pains to begin leading an active lifestyle, you will never get started. Be creative, adapt and overcome. You can exercise without putting too much stress on your feet. Try swimming laps, stationary bicycling or lifting weights. Just make a small change for now, but whatever you do – don’t wait until you feel better.

Walk well.

Link to Lower Extremity Review Article:

http://lowerextremityreview.com/editor_memo/out-on-a-limb-fit-vs-quit

No more rotten apples. Otherwise entitled – how to pamper your fascia.

We have already talked about the causes of Plantar Fasciitis, and how to counteract those factors with a well-planned stretching program. Let’s go a step further (ha ha) and look at what you are actually wearing on your feet.

What not to wear:

In the Pedorthist clinic where I am working, I do an hour-long consultation with each new patient. I spend only about 20 minutes of that appointment actually looking at their feet. The rest of the time I am examining their shoe collection and watching them walk both barefoot and in various shoe/ orthotic setups. Very, very commonly (like maybe 8 times out of 10) I can pick a pair of shoes out of their collection and say “I am pretty sure that you were spending a lot of time wearing these shoes right before your symptoms started to appear.”  (More about that later).

Each step you take in bad shoes can cause damage to your feet, especially to your Plantar Fascia.  I look at each step you will take in the future as an opportunity to prevent or even reverse this damage. What you have to do is commit to wearing the right things on your feet. You may have to temporarily sacrifice style, but believe me – it is worth it if your feet don’t hurt.

There are 2 things a foot with Plantar Fasciitis needs: shock absorption, and support in proper alignment. Basically, you are trying to “pamper” your feet in order to reduce the amount of stress and strain on your fascia.

Orthotics:

Sometimes an appropriate shoe can provide everything you need. But if you have an underlying biomechanical issue, such as extreme pronation or supination you are probably going to need some additional help from orthotics.

Custom orthotics made from a mold of your feet are the industry ideal (I tell my patients that they are the “Cadillac” of the orthotics world).  But they tend to be really expensive (avg. $400). For those of us who aren’t ready to shell out that kind of dough, there are a wide variety of over-the-counter supports that can be helpful.

Two of my favorite products for this situation are: (Both brands are intended to prevent excessive pronation, but are somewhat effective for slight supinators.)

–          Superfeet – the durable plastic shell can hold up to heavy hiking and athletic activity, they are best suited for wide, low arched feet.  Buy these for about $40 all over the internet and in many sporting goods stores.

–          Birkenstock Blue – These cork inserts are best for medium to high arch feet and they come in 3 widths. Their most unique feature is the built-in metatarsal arch support.  These should cost about $70, they are hard to find in actual stores, you will probably have to buy them online.

http://stores.walkpro.com/catalog/birk2.gif

Shoes:

Remember how I claimed that I could usually tell which shoes caused the Plantar Fasciitis flare up?

Here are the common denominators between those bad shoes:

1.       They are worn out

Shoes are not like a fine wine – they do not improve with age. If they look worn out, they probably are. DON’T KEEP WEARING THEM!!! Trust me, it is much cheaper to buy a new pair of shoes then it is to pay all the appointment copays and orthotic expenses after the damage has been done.  And another thing, don’t save your new shoes for “special occasions” because then you end up wearing your old ones all the time while the new shoes sit in your closet in pristine condition and your feet grow steadily worse. That is like eating the rotten apples out of the bushel first, and when you finally get to the good ones – they’ve gone bad too!

2.       They do not fit well

I am only going to say this once (actually, that is probably not true…): Buy shoes that fit you. The widest part of your foot should fit into the widest part of the shoe. You should have about 3/8 to 1/2” of room to spare between your longest toe and the end of the shoe. Buying shoes any larger than that allows your foot to move too much inside the shoe – you aren’t getting enough support. Also, do not buy your shoes too small. Your toes should not touch the end of the shoe when you step down; your foot needs room to expand as you put your weight down on it.

3.       They show significant compression of the midsole

I showed you this alignment trick in a previous blog:

Put your shoe on a flat surface and make sure that it doesn’t lean too much from side to side. If you do notice an angle, the chances are that you have packed out the foam in the midsole.  Look closer and you will probably notice a network of very thin compression lines in the foam; this is usually most noticeable in the heel of the shoe.

4.       They have a week heel counter

5.       They have a poor level of torsional stability

I am going to lump both of these last two problems together, because they are most frequently found in the same type of shoe – namely: minimalist footwear. Now this is neither the time nor the place for me to go off on an anti-minimalist rant, but let me just say that these shoes don’t work for everyone. Most people just need a bit more support.

http://drshoereviews.com/2012/09/

http://www.runnersworld.com/community/forums/runner-communities/barefoot-running/first-pair-of-minimalist-shoes-picture

See the problem? If you can fold your shoes up into a pretzel, it is probably a good indication that they are not going to “pamper your fascia” by providing either shock absorption or support.  Throw them out like the rotten apples that they are…

Below is a little cheat-sheet of shoe anatomy just in case you got lost in any of those terms:

Following are 3 of my favorite choices for a Plantar Fasciitis recovery shoe.  If you are serious about getting better, then you are going to need to pull out all the stops: get fitted for orthotics (OTC or custom, depending on your issues), ACTUALLY DO YOUR STRETCHES, and get yourself a good, sturdy pair of shoes to wear.  For your convenience, these shoes are arranged in order according to their level of correction and their degree of ugliness.  Pick your poison:

–          Brooks Ghost:

The Ghost is a luxury shoe. The cushioning is superior, which helps to take some of the strain off of your fasciitis. This is a neutral shoe, so it won’t correct your alignment much – it is best for those who just slightly supinate or pronate, and people who aren’t too heavy.

http://www.brooksrunning.com/Brooks-Ghost-5-Mens-Running-Shoe/1101191B068.080,default,pd.html?start=1&q=ghost

–          Asics Gel-Evolution 6:

This is a beefy anti-pronation shoe. I would recommend it only if you are sure that you are a pronator. The vast majority of people who develop Plantar Fasciitis experience some degree of excess pronation, so I feel comfortable recommending this shoe here. The sole has dual density foam that is more firm on the medial (arch side) of the shoe. This design is intended to reduce pronation at heel strike.  Asics’ signature gel in the heel provides nice shock absorption and the thick midsole is very supportive.

http://www.asicsamerica.com/footwear/running-shoes/gel-evolution-6-t164n-womens/

–          NEW BALANCE 587:

I know, I know…it’s as ugly as sin. But you know what? It is the ultimate in both support and durability. One of the few shoes that works just as well for both pronators and supinators, it is as steady as a rock and it has a high heel elevation that helps to reduce any amount of pulling from tight muscles in the back of your legs. Just tell yourself it is only for a short time – I promise, a few months after you start feeling better you can move to something a little more fashionable.

http://www.newbalance.com/New-Balance-587/W587,default,pd.html

Well, if you have a long enough attention span to reach the end of this blog – you are to be congratulated: you are either in serious Plantar Fasciitis pain or you have a lot of time on your hands. I hope this shoe/ orthotic advice was helpful to you. Throw out those rotten apples, buy yourself some good footwear and walk well.

Fat Pad Atrophy: you don’t know what you’ve got ‘till it’s gone

Q: What do feather beds, swimming pools and leaf piles have in common?

A: Fat.

What, that’s not the answer you were expecting? But it’s true. Think about the reason why you can jump into a pool or leaf pile or feather bed. Because you know you will have a soft landing; the water, leaves and feathers will protect you from hitting the hard ground. The fatty deposits in our bodies were designed for a similar purpose – to insulate and protect our fragile organs and also to help absorb shock in our skeletal system.

Did you know that you have fat in your feet?  And it’s a good thing too.

The blue markings on the foot above show the areas that are covered by a thick fat pad. You will notice that it pretty much corresponds to every part of your foot that touches the ground. This is not a coincidence. We contact the ground with a relatively small surface area that is comprised of the boney structure of our feet. The pressure in these areas can measure up to more than 8 times your body weight as you go about your daily activities.  Cushioning is necessary to say the least.

The adipose cells in the fat pads of your feet act a little bit like the plastic balls in a playground ball pit.

The cells are small, individual packages of fluid that squish around independently to adjust to the surface you on which you are standing and the area of the foot that needs padding at the time.

As we age, the fatty padding on the bottom of the foot tends to disperse and thin. This is called  “Fat pad atrophy”. Older people and those who spend excessive time walking or standing on hard surfaces are especially susceptible to this condition.  High arch feet are also more likely to experience this problem because they have a disproportionally small amount of ground contact area, leading to heavy pressure spots in the heel and under the metatarsal heads.

Think of fat pad atrophy as being like a ball pit that doesn’t have enough balls.

There is little to no shock reduction in most areas, leaving your bones directly exposed to pressure and pain from contact with the hard ground.

The foot below is supposed to illustrate fat pad atrophy:

See the green spots? They represent adipose cells that have gotten squished down and displaced to sides. The red and orange areas show places where repeated pressure on the uncushioned bones can cause damage and pain. You notice that there is a lot of fat squished towards the outsides of the heel and underneath the crease of the toes. Many of my patients with fat pad atrophy tell me that it feels like their socks are wrinkled up under their toes all the time.

One of the best treatments for fat pad atrophy is a pair of soft, cushioning orthotics. This is one of the few occasions when I advocate the use of those nice, squishy, gel inserts that you can buy in every pharmacy. If the problem is not too severe, these cheap over the counter inserts will work wonders. Unfortunately, fat pad atrophy is often accompanied by (and probably originally caused by) an underlying alignment issue, such as supination or pronation.  If this is the case, the best solution is a set of custom molded orthotics built with high sides to surround the foot and push the fat pad back underneath.

Wearing well made, cushioned shoes will also be an important part of overcoming fat pad atrophy. One of my favorite shoes for this purpose is the Brooks Dyad. This sneaker is like a marshmallow that you tie onto your feet. It manages to be extremely cushioned while still providing a reasonable amount of support and stability.

Fat pad atrophy will never fully go away, but if you are diligent about providing your feet with extra cushioning, your pain will gradually subside as the damage on your bones has a chance to heal.   The moral to the story is – don’t take your fat for granted!

Walk well.

Pictures from:

http://www.footphysics.co.uk/wp-content/uploads/fat-pad-of-the-foot-274×343-239×300.jpg

http://1.bp.blogspot.com/-o2pGB9eag7E/ThNhZ9REoDI/AAAAAAAABns/aYskzFdkpAM/s1600/39799.56402.file.eng.ball-pit-feet-main.345.202.jpg

http://movieboozer.com/wp-content/uploads/2012/06/image0042.jpg

http://www.wrymark.com/images/shelf/diabetic.jpg

http://www.brooksrunning.com/on/demandware.store/Sites-BrooksRunning-Site/default/Search-Show?q=dyad

What’s wrong with this picture?

I know it is a little bit weird, but I am always watching the way people walk. It’s like a game I play with myself: guess the injury, name the solution. I like to think that this funny habit keeps my brain active and stops me from being bored. Last week I saw a couple of people walk by who had major problems. You have heard the expression “The cure is worse than the disease”? Both girls were in the process of recovering from an injury but at the same time were setting themselves up for further damage because they forgot to consider the rest of their body. I am sharing these pictures to encourage you to avoid “tunnel vision” next time you have an injury. Don’t just focus on the things your injury needs in order to heal – think about the rest of you; make sure you are not creating a second problem.

Problem #1: Aircast Abuse

                              

This girl is wearing an Aircast on her Right ankle.

Aircasts are very frequently used to recover from an ankle sprain, usually only during the acuteStage (The term acute means that the injury just happened recently and is still getting better…it does not refer to an injury that is adorable). The whole purpose of an Aircast is to support the ankle and provide a little bit of compression at the joint to reduce swelling. The sides of the brace are hard plastic cushioned by soft pockets of air that conform to the shape of the person’s leg. The girl in the picture is wearing her Aircast with flip flops.

This is a grave error.

Two major problems occur when you wear an Aircast with flip flops:

–          Aircast braces rely on the sides of the shoe to stabilize the brace. If there is no shoe, the Aircast is literally useless. The whole point of wearing an ankle brace is to provide support to the ankle, but you have to remember that the brace works as part of a System. It’s like a peanut butter and jelly sandwich: you need bread, peanut butter and jelly. If you are missing any one of these three components, you won’t have a PB&J.

–          Even if the Aircast was able to magically support this girl’s ankle without the help a shoe, a flip flop is still not an acceptable rehabilitation footwear choice. Here is why: When one part of your body is injured, your entire system is under stress. Think about if you have a back porch with one rotten board in it. You are going to step around the rotten spot because you know that it is weak. This will put more stress on the other parts of the structure, possibly causing strange wear patterns or weakening adjoining areas.

The same thing happens when you hurt a part of your body. This girl has injured her Right ankle, so the chances are good that she will try to compensate by putting more weight on her Left foot. Now ask yourself: is that foot well supported? No. That flat flip-flop is doing precisely nothing to ensure that she has proper body alignment from the ground up.  She is not only neglecting her injured ankle, but she is also setting up the rest of her body for a compensation injury.

Problem #2: The (not really) walking cast

The girl above was spotted hobbling though a store with her Right foot in a nearly knee high cast. The cast had a protective “shoe” that was intended to preserve the plaster.  In order to walk through the store, she had to turn her Right leg so that her toes pointed outward (Abduction of the hip) and lean her body weight forward so that she could fall heavily onto her Left foot. She would then swing her Right leg around and forward to get ready for the next step. It was a painful process to watch.

There are a lot of issues here, but let’s just name a few.

–          She is wearing a loafer on her Left foot. (See the above rant about flip flops not being supportive – loafers are just about the same) You can actually see her Left foot pronating in this picture as she struggles to balance most of her weight on her un-injured leg.

–          I am going to assume/ hope that she was not actually supposed to be walking on her cast yet. The reason for this is because she is not properly equipped to walk in that cast. When your foot and ankle are “locked” in a 90° position (the way this cast is splinting her leg) it is almost impossible to have a smooth gait pattern. You actually need to be able to dorsiflex (bend your ankle so that the top of your foot gets closer to the front of your lower leg) at least 10° in order to walk normally.

–          Because it is so hard to walk without bending your ankle, a cool innovation called a “rocker sole boot” has evolved over the years. There are several types, ranging from the kind that Velcro over the existing cast to a type of boot with an external shell that works instead of a cast. This same rocker sole effect can also be built into the cast by inserting a rounded metal plate into the bottom of the plaster. If this girl was supposed to be walking around, I expect that the Doctor would have provided her with a rocker sole so that she could have a smooth gait.

–          If this girl continues limping along with her incorrect gait, she shouldn’t be surprised if the following  compensation issues begin to arise: (in order of likelihood and occurrence)

• That same day – she will start getting a tension headache/ sore neck from holding her head at a weird angle all day without realizing it. Her Right hip flexors will also start to become really tired.
• The next day – she will feel a knot developing behind her Left shoulder. This is because she is having to use her upper body to gain enough momentum to swing her injured leg forward at the beginning of each step.
• Later that week – Her Left arch and or shin will begin to cramp and burn at the end of the day. This is caused by her perpetually shifting her body weight to her uninjured side. If she does not begin to wear supportive footwear and stretch her calves, her Left foot will become a prime candidate for plantar fasciitis within the month.
• For months after getting rid of her cast – she will notice a mysterious ache in her lower back/ Right hip area. This is because her Right leg has essentially been acting like it is longer than her Left leg (because of both the thickness of the cast and the lack of ankle motion). This functional leg length discrepancy stresses her hip and lower-back because she is trying to control her balance so that she does not fall onto her Left leg with excessive force.

You can see that if the above problems are not addressed, the girls in the pictures could become vulnerable to a wide variety of ailments, aches and pains. These sorts of compensation injuries creep up slowly and often can significantly complicate and prolong the rehabilitation period. Don’t let that happen to you. The next time you are limping along because of a recent injury, take a look at yourself: Are you wearing good shoes? Are you walking as naturally as possible? Remember that your body works as an entire system, when one part is broken all the other pieces are also stressed. Take care of yourself from the ground up and give your body every advantage while you are recovering from injury.

Walk well.

Photos From:

Concord Market Days, Concord, NH. Photo credit: Colin Widhu

http://prohealthcareproducts.com/images/aircast-leg-brace.jpg

LL Bean, Freeport ME. Photo Credit: Bob Smalley

http://www.bearmountainpainting.com/wp-content/uploads/2012/04/rotted-deck-replacement-wood.jpg

Anti-pronation orthotics: The Wise Man Built His House upon the Rock

In my last post I was pretty stern about the fact that not everyone who pronates needs orthotics. I went so far as to say that anyone who needs orthotics also needs to do strengthening exercises and wear proper footwear.

Enough lecturing. The good news is: Orthotics can really do wonders – as long as they are the appropriate kind.

The experts will tell you that all orthotics fall into one of two categories; they are either Accommodative (made out of soft material like foam) or Functional (consisting of hard plastic and rigid material).  The discussion about the differences and merits of these two types can be confusing and technical so I won’t bother talking about it…what you need to know is that some orthotics are intended to cushion the foot, and others are meant to control the foot.

Cushioning – fresher air ≠ cleaner house

Cushioned orthotics are soft and squishy and they conform to the shape of your foot – anything with gel or memory foam falls into this category. This is the kind of insoles that you will find if you walk into the arch support section of your local pharmacy. The reason stores stock this type of insert is because they are fun, they feel good, and it is really easy to get people to buy/wear them. Below is a picture of one of Dr. Scholl’s famous gel insoles. Don’t be fooled by the cool colors and designs – they really just add a bit of cushioning.

Cushioned orthotics do have their place – some people have painful areas in their feet that always get too much pressure (caused by a bone spur or some other abnormality). But they are not the solution for every situation.

An analogy comes to mind: think of another popular product often found in pharmacies: Air freshener. Everyone loves it right? It makes your house smell like a million bucks. Even when you fried onions for dinner or forgot to empty the trash can. But there are times when air freshener just won’t cut it – like when you have a stinky dog living in your house. If you just keep spraying the air freshener and you never wash the dog your underlying problem is never resolved. Your house stinks because something in it is dirty, not because you need to use more air freshener.

In the same way, well cushioned pronated feet are still pronated feet. You may have some extra bounce in your step, but if you haven’t fixed the pronation issue all you did was mask the symptoms.

This is a story about CONTROL….

Don’t worry, I am not about to break into a Janet Jackson song. But it’s true – Pronators need control! Trying to control pronation with something soft and squishy is like the foolish man building his house upon the sand. (oh dear, another song…) If you pronate badly enough to need arch support (in other words, you can’t control it with only good shoes and exercises) then don’t mess around; get yourself some solid orthotics.

If any of the following apply to you:  extreme pronator, abnormally high arch feet, incredibly flat feet, or if you are especially tough on your feet (like an athlete or someone who stands all day at work) then you are going to need custom orthotics. These can be made for you by a Podiatrist, Orthotist or Pedorthist. In order for them to be truly custom, they have to have been built around a mold of your feet and then specifically fitted to your individual footwear. Whoever makes them for you MUST watch you walk in them and be able to adjust them as needed. If they can’t do that, take your business somewhere else.

Everyone else who falls into the “normal-ish” foot category can probably get away with using over the counter arch supports to control their pronation.  I have two favorite brands for this situation:

#1: My top over-all choice for best performance and good price = Superfeet

I love Superfeet products. They are well made and have been around forever so they have been field tested and improved based on real life feedback. Order according to your shoe size if you are going to try to buy them for yourself…but it really is best to get them fitted to your arch length by a professional; pay a few extra bucks the first time and then you can always buy more pairs of the same size on your own later. They are really easy to find in a lot of sporting goods stores and all over the internet.

#2: my second choice, just because they are a little more expensive and harder to find = Zapz

These insoles are a product of the custom ski boot fitting industry and are distributed by the America’s Best Bootfitter’s http://www.bootfitters.com/ . Zapz insoles have a deeper heel cup than the Superfeet products which adds a bit more motion control, they also feel a little bit softer underfoot because of specially placed pads under the heel and forefoot which absorb extra shock. Zappz can be slightly customized by heating them in the microwave, but they do tend to have a shorter lifespan as compared with Superfeet which means they have to be replaced about once every 6 months to 1 year.

Orthotics are a great tool which, when used correctly, can reduce your pronation and allow your legs to function in their proper alignment. The right pair can make a big difference. Build your house upon a rock, don’t waste your time with “air fresheners” – spend your money wisely on a good pair of either custom or quality OTC orthotics that provide stability. Don’t forget that even the best orthotics can’t do it all; it is still up to you to strengthen your weak muscles, stretch your overactive muscles and wear good quality shoes.  Walk Well.

Pictures from:

www.target.com

www.Biglots.com

http://www.superfeet.com/products/Green.aspx

http://www.masterfitenterprises.com/microwavable_custom_orthotic_insoles.html

Orthotics to Control Pronation – elephants, crooked houses and bleach

During the last few posts I have been discussing what pronation is, and how to control it using supportive shoes and targeted exercises.  But up until now I have ignored the elephant in the room. Orthotics.

There are a few reasons I have left this topic for last; mostly because it is complex but also because it’s controversial. People who make orthotics, like Podiatrists or Pedorthists, tend to say that anyone who pronates (and that is pretty much everyone) needs some form of arch support or orthotic.  I think this approach might be a bit excessive.  Rehabilitation experts, exercise specialists and Physical Therapists usually tend to claim that all pronation problems can be resolved with strengthening and stretching.  I think this perspective is an unnecessarily slow solution to the problem of pronation. As with most subjects, the real solution probably lies somewhere between the two extremes. I think the following principles are important to keep in mind any time you are thinking about using orthotics to correct pronation:

Not everybody needs orthotics.

You have heard the expression “if it ain’t broke, don’t fix it”…well, I would like to apply that same sentiment (with a few minor tweaks) to the idea of using orthotics. My new adage would be “if it hasn’t caused a problem yet, and you don’t think it is likely to…just leave it alone.” I know this saying is not as catchy as the old one…but oh well – it was the best I could come up with on short notice.

To illustrate this point, I would like you to consider a picture of a crooked house:

Imagine what would happen if you decided that you wanted to straighten out the entryway on this building. A new, square, prefabricated door would never fit correctly. You would have to tear out and replace all the old hardware and the door frame and probably quite a bit of the wall.  Even if you did make it work, it would look funny and the chances are that you would have created a whole variety of other problems that you didn’t want to deal with. Hippocrates understood this concept, which is why the first part of the oath that is (or should be) drilled into every medical professional’s mind reads “First, do no harm”.  Some houses are just meant to be crooked; some people just weren’t intended to have textbook biomechanics. The word Orthotic comes from the Greek root Ortho- which means “to straighten or to correct”.  But not everyone really needs correction; some people do just fine without it.  How can you tell the difference? Trial, error and good judgment – which is why it is important get advice you can trust.

But some people sure do!

Take a look at this house:

This is a place that needs some serious help. The gaping hole in the foundation has impacted the entire structure. This building is clearly having trouble because of its crookedness. Instead of adapting to a new angle like the place in the top picture, this house is crumbling apart. Sometimes pronation is a big deal and peoples’ bodies are unable to handle the crookedness. These people may experience severe injury and chronic symptoms because of the collapse of their support system if they are not given some correction before it is too late.

Pronators need orthotics if:

–          They have classic pronation symptoms

• Medial knee pain
• Low back and hip pain
• Ankle pain
• Bunions/ painful toes

Or:

–          They put their feet through excessive stress, creating a high injury risk

• High body weight (not just obese people, but anyone who is tall or muscular too)
• Lots of high impact activity (athletes, hikers, people who are on their feet all day)
• Long periods of static standing (Standing still is harder on your body than walking, especially on a hard surface)

Orthotics are just one part of the solution

I want to switch analogies here from crooked houses to a laundry stain

If you have a minor stain on your shirt, you will most likely try to get it out with soap and water. If that doesn’t work, your next move will probably be using extra strong laundry detergent when you put it in the washing machine, and if you really can’t get the stain out you might have to use a stronger chemical such as bleach.

Pronation control is a bit like this; if the problem is minor, you can probably solve it with just some good quality, supportive shoes. If the pronation issue persists, you may have to add some exercises into the mix. If you can’t control your pronation with these two options then you have to pull out the big guns and use orthotics. But keep this in mind: Orthotics can’t do it all! If you need orthotics then you also need good shoes and you should be doing some basic exercises as well.

In my next blog I will be giving you an overview of the different types of orthotics that can be used to control pronation. Until then, walk well!

Pictures from:

http://boldt.us/humor/the_crooked_house_banks_ales.html

http://lostinasupermarket.com/wp-content/uploads/2010/03/michbrush1.jpg

http://www.videojug.com/film/how-to-remove-grass-stains-from-clothes