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Orthopaedic Shoe Repairs
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Some Feet Problems that need Orthopaedic Shoes
Flatfeet
Flatfeet (or pes planus or pes valgus) simply mean a foot where there is
no arch present. Flatfeet can be either flexible or rigid. The typical
flexible flatfoot is usually asymptomatic. The child is taken to the
physician because of the appearance of the foot, as families are concerned
that the child's foot is rolling over with the child appearing to walk on
the inside of his/her ankles. There is also concern that the child will
not suffer a similar fate as some other adult in the family who has
painful flat feet.
Most children do not begin to form an arch until about ages 3-5, so it is
very common for flexible flatfeet to exist before this age. Eighty percent
of children will develop an arch between the ages of 3 and 10 and for the
20 percent who do not, the condition is usually not painful. However there
are some children with genetic problems such as Down's Syndrome or
Marfan's Syndrome where the ligaments of the foot are lax, allowing the
arch to fall, producing flat feet. These children are predisposed to
flexible flatfeet and are more likely to become symptomatic that normal
children due to the genetic ligament laxity.
For the vast majority of children, no treatment is ever necessary for
flexible flatfeet. Studies show that there is no link between having
flexible flatfeet and developing pain and foot problems later in life.
Only the most severe flexible flatfeet produce pain.
The only reason to treat flexible flatfeet is when children are
experiencing pain or having significant difficulty wearing through their
shoes. In these cases, arch supports, and rarely braces (such as a UCBL)
are used to help alleviate symptoms. Several excellent studies have shown
that there are no specific types of shoes, arch supports, or braces that
will lead to the development of an arch. These shoewear modifications only
serve to help diminish symptoms by supporting the foot, they do not
correct or reverse the deformity. The arch supports or brace are usually
used between ages 3 to 10 to help treat symptoms and prevent the deformity
from worsening, so that no pain or problems should occur as an adult. It
is extremely rare to need surgery to correct a painful flexible flatfoot
when arch supports or bracing has failed to improve symptoms.
Rigid Flatfeet arise from some type of abnormal foot development. This can
be in the form or a congenital problem that the child is born with such as
a vertical talus (convex pes valgus) or from an abnormal connection
between bones in the foot that are not supposed to be connected (tarsal
coalition). Rigid flatfeet are more serious than flexible flatfeet and are
often painful and usually require treatment.
Vertical Talus
A vertical talus (convex pes valgus) is a rigid flatfoot where the talus
(the lower bone in the ankle joint) is abnormally positioned in relation
to bones in the middle part of the foot. This creates a rigid flatfoot
that appears like a rocker bottom. This deformity usually is present at
birth. It can be associated with neuromuscular conditions such as
arthrogryposis or spina bifida, or it can occur on its own in an otherwise
normal child.
Some studies suggest there is a hereditary component and others suggest
that abnormal intrauterine positioning can cause the derformity. If left
untreated, the child will walk on the bottom of his abnormal talus,
causing a callous to form and eventually a painful foot. If the deformity
progresses, it becomes difficult to shoe the foot, the callous may lead to
skin breakdown, and the child will walk with a "peg leg" style with
problems pushing off on the foot. Participating in normal childhood
activities is extremely difficult and painful.
The earlier treatment is instituted, the better the result. This
abnormality almost always requires surgery to correct, often with a period
of stretching and casting prior to the surgery. Treatment begins as soon
as the deformity is recognized with an attempt to stretch the foot with
casting and/or manipulation. This alone will not completely correct the
foot. The foot is usually operated on after 6 months of age and hopefully
before age 2. The surgery consists of opening the foot and reducing the
dislocations of the foot and pinning the bones in place followed by
casting and ultimately bracing. Tendons may need to be lengthened as well
depending on the degree of deformity. It is not uncommon for this
deformity to need further surgery as the child ages, as the deformity may
recur. Further surgery consists of fusing the bones in place to prevent
any further deformity. This is only done in the older child when the foot
is close to maturity. Despite surgery, these feet will be stiffer than
normal feet but should be significantly better shock absorbers than if
left in the deformed position.
Tarsal Coalition
A tarsal coalition is an abnormal connection between two bones in the foot
that are not normally supposed to be connected. This occurs as a result of
abnormal formation of joints during fetal development. The most common
coalitions are between the calcaneus and the navicular bones and the talus
and calcaneus bones. The coalitions are either fibrous, cartilaginous, or
bony connections between the two bones. The coalition makes the foot less
flexible and causes undue stress on other parts of the foot. Often the
coalitions are present at birth and progress from fibrous to cartilage to
bone, becoming more stiff with age.
As a result, children do not usually present to the doctor with this
condition until the late first decade or early second decade of their
lives. They often come in after an ankle sprain that "just never seems to
get better", or that their foot is stiff and painful. Coalitions can occur
in both feet in up to 50% of patients. On examination, the flatfoot is
usually rigid and painful, and not correctable to a neural arch. The
peroneal tendons are often is spasm (another name for tarsal coalition is
peroneal spastic flatfoot).
The condition is initially diagnosed by X-rays and confirmed with either a
CT scan or an MRI. Initial treatment is aimed at reducing symptoms by
conservative means. This can consists of arch supports, bracing, casting,
and/or anti-inflammatory medication. If these measures fail to relieve the
symptoms, surgery to excise the coalition is considered. In the case of
the calcaneo-navicular coalition, muscle is inserted in the gap after the
coalition is excised to prevent reformation of the coalition. Depending on
the size of the talo-calcaneal coalition, the coalition is either excised
and replaced with fat, or the coalitions is excised and the remainder of
the joint is fused. After successful surgery, reformation of the coalition
is prevented and symptoms are usually resolved.
Superior Quality at a modest price. Prices on
application.
24 to 48 hour service
Items can be despatched by courier for next
day delivery.
Economy courier service 2 - 3 days
145A Hatfield House Road, Sheffield S5 6HX
Orthopaedic Shoe Repairs Montgomeryshire
Ankle Injury: Understanding Ankles
S & MT, SUMMER 1998
Ankle injuries have long been the dread of all athletes and sports professionals. One tumble could mean being out of action for more than 3 months, and sometimes even the end of a career. An estimated 1 in 10, 000 people sustain an ankle injury each day, and some 5% do not fully recover. The typical sorts of ankle injuries that are commonly experienced fall into two categories: acute sprains or overuse injuries.
Acute injuries
Actions such as pivoting on the ankle can create extreme pressure on the ligaments, leading to tearing or disruption of the ankle's outer ligament complex. The effects are immediate bleeding and swelling around the outer border of the ankle and difficulty in bearing weight. It is important to take quick action. In these cases conservative treatment is best. This includes:
Immediate rest
Ice compression
Elevation
Physiotherapy
Some specialists prefer a two to three week period immobilising the injured ankle in a walking plaster cast to reduce chronic instability and further problems. In either event, after six to twelve weeks, around 95% of these injuries go on to make a full recovery.
Overuse injuries
During any game of sport, the ankle is subjected to enormous pressure. Over time, a variety of injuries can occur. When repetitive minor injuries occur to the achilles tendon, swelling, inflammation and partial tears to the collagen fibres are produced. This condition, known as chronic achilles tendonitis is very difficult to cure. Such injuries are fairly common in the professional sporting arena. Treatment often involves long periods of rest, physiotherapy, the use of ultrasound and the modification of footwear.
In mildly arthritic or worn ankle joints, small pieces of bone may break off. This can present with pain, swelling, locking and a sensation of instability and occasionally the joint can give way.
Other overuse injuries to the ankle include the generation of bony spurs on the front of the ankle. This causes pinching within the ankle during running, particularly during the 'heel-off phase of the running cycle.
For those who have injured themselves whilst playing sport, it is best to stop playing immediately as continuing can further aggravate the injury. As a rule, it is generally unwise to run through pain in the ankle or achilles. Pain is, after all, the body's way of telling us that something is wrong. Similarly, if joints are regularly locking, clicking or giving way, this is an indication that something may be amiss. What must be taken into account is that during exercise the body secretes its own morphine-like substances which can mask the pain arising from a damaged joint, muscle or tendon. Such parts of the body normally issue signals of pain because there is an underlying problem. Athletes ignoring such symptoms are more likely to develop further problems later in their careers. Resting, applying ice and some compression to the injured ankle whilst elevating it will ensure that no further immediate damage is done.
If, after a course of physiotherapy, symptoms fail to settle down after the usual six to twelve week healing period, sports professionals who continue to get pain, swelling, clicking or locking in their ankle after this period should seek referral to a specialist for treatment. X-rays and magnetic scans of the ankle are taken to access the joint and detect conditions such as residual ligament instability, the presence of bony spurs forming at the front of the ankle joint, loose bodies or scar tissue.
Until five to ten years ago surgery was a lengthy and painful ordeal. Surgery required the patient to stay in hospital, certainly overnight and more usually for two or three days. In order to access the joint, the surgeon had to make a fairly large incision, which, combined with the effects of the general anaesthetic added to the recuperation period. Furthermore, the patient left hospital on crutches, often in plaster, with a sizeable scar. In practice, very few ankle injuries could be treated and the results of
surgery were often unsatisfactory. The joint was just too small for the instruments available and for surgeons to see inside the joint.
The future of ankle surgery
Technological developments have led to ankle arthroscopy or keyhole surgery, which has transformed the treatment of ankle injuries. Two or three tiny holes are made around the ankle, into which 2mm wide fibre-optic scopes are fed. Surgeons are able to carry out the intricate range of repairs and procedures whilst watching the operation onscreen. This type of surgery can usually be undertaken as a daycase procedure. Patients typically experience very little post-operative pain and are able to walk out of hospital with no difficulty.
Results are better, there is less discomfort involved, shorter hospital stays, lower complication rates and shorter recovery times. The cosmetic results are better
too n very often just a couple of tiny scars that are barely visible or quickly fade. Rest and elevation of the limb is prescribed for the first 48 hours, followed by a supervised physiotherapy programme.
Ankle arthroscopy has revolutionised the work of the orthopaedic surgeon, both in diagnostic techniques and in surgery. Both standard x-rays and magnetic scans miss problems in the ankle, particularly where the damage is to the soft tissue. Arthroscopy as a diagnostic tool is virtually 100% accurate, enabling exactly the right treatment to be administered. The success rate of the treatment is also high. For example, the pain of soft tissue lesions can be alleviated in 84% of case whilst arthroscopic ankle fusions carry a 95% fusion rate. Sprains, fractures, torn ligaments, rheumatoid arthritis, degenerative disease, loose bodies and bone spurs can all be treated by this method.
ArthroWand
Developments in technology have meant that surgical instruments used in arthroscopy are becoming smaller and smaller. One of the latest weapons in the surgeon's armoury is the ArthroWand used for the process of `coblation'. Coblation, derived from cool ablation, is a new technique for removing damaged soft tissue, rapidly and precisely with minimal damage to surrounding tissue. The process uses radiofrequency energy to remove the tissue through a significantly cooler process than is possible with traditional electrosurgery. The method disintegrates tissue layer by layer, giving the surgeon excellent control to remove tissue whilst leaving the healthy tissue intact.
Before the coblation wand, options available to surgeons included traditional electrosurgi-cal tools and lasers. These work by a heat-driven process that can produce thermal damage in tissue surrounding the area of surgery. The coblation wand applies radiofrequency energy to convert the fluid found in the gap between the wand and the tissue into an ionised vapour layer called plasma. Charged particles accelerate through the plasma and gain sufficient energy to break the molecular bonds within cells. This literally causes the cells to disintegrate molecule by molecule, so that tissue is removed. As this effect is confined to the surface layer of target tissue, and at lower temperatures, thermal damage to the surrounding tissue is minimised. As a result, the coblation wand improves operative precision and efficiency for the surgeon. The patient enjoys reduced postoperative pain, less bleeding, reduced surgical time and a speedier recovery.
Case study
S. is a keen runner who in his younger days played a lot of rugby and football. About five years ago, he noticed that his ankle had started to give way, particularly when he was bending his knee over his left foot. He visited a sports physiotherapist who prescribed a short course of physiotherapy. The pain continued to worsen and S. was referred for further specialist investigation.
An X-ray revealed "Footballers ankle" also known as a tibial spur. The operation took place on Friday to remove the spur and on Saturday, Steven went home with just two small stitches on either side of his ankle. By Monday, he was back at work. Just one week later, the stitches were removed and he had some physiotherapy to work the joint and muscles. Not long afterwards, he started running again.
W., a professional dancer, also depends on his ankle for his profession. He was appearing in a musical show and was coming off stage when he fell down some stairs. iI heard what I can only describe as a`pop' and my ankle literally gave way underneath me, i he recalled. He immediately went to hospital and was put in plaster for three days. Rest and physiotherapy were prescribed and he was told all would be well within six weeks.
Nine weeks later, with the ankle still swollen and painful, S. returned to work. iIt was agony and really I was only operating at about 40 per cent. I honestly thought I might be finished as a dancer, i he said. After an initial consultation, S. underwent an ankle arthroscopy to remove a spur and meniscoid band. He had the operation, stayed in overnight, and then left hospital wearing a crepe bandage. He was allowed to return to work two weeks later.
Take preventative measures
However good today's technology has become, it should not be used as a substitute for careful history taking, examination and investigation. Prevention is always better than cure and for those who lead an active life or are involved in regular sport, joint flexibility and regular stretching programmes are key. Stretching calf muscles, hamstrings and quads is the main route to preventing foot and ankle problems. The muscles act as shock absorbers for the skeletal system. Short, tight muscles have less shock absorbing capacity. This means that athletes with these types of muscles pass more of the force of their activities on to the joints. This increases the forces going through the joints or tendons, making them more liable to injury.
Good footwear is another means of avoiding injury. Well fitting shoes with a shock absorbing system built in will
help. Beware, however, such shoes lose their shock absorbing capacity after about three months of use. Sorbathane rubber insoles may extend the life a little.
Ankle arthroscopy is gradually becoming a very important tool in the sporting world, and is helping to extend the professional careers of some athletes and sports professionals.
Mr Simon Moyes MB FRCS FRCSOrth is a Consultant Orthopaedic Surgeon at the Wellington & Devonshire Hospitals, London and webmaster of www.simonmoyes.com which is the source of this article.
"Orthotist", "orthopaedic brace" and "ankle-foot orthotic (AFO)" redirect here,
where they are dealt with in their respective sections.
Two different braces used to treat scoliosis
Orthotics (Greek: Ορθός, ortho, "to straighten" or "align") is a section within
the medical field concerned with the design, manufacture and application of
orthoses. An orthosis or orthotic (plural: orthoses or orthotics) is an
orthopedic device which support or correct the function of a limb or the torso.
An orthopaedic brace, "appliance", orthotic, or simply brace is an orthopaedic
device used to control and/or guide and/or limit and/or immobilize an extremity,
joint or body segment for a given reason; to restrict movement in a given
direction; to assist movement more generally; to reduce weight bearing forces
for a particular mobility purpose; to help with rehabilitation from fractures
after the removal of a medical cast; or to otherwise correct the shape and/or
function of the body to provide easier movement capability and/or reduce pain.
It combines disciplines of study within the health and physical sciences,
mathematics and engineering ie materials engineering, gait analysis, anatomy and
physiology, patho-physiology, biomechanics, and psychology contribute to the
work done by orthotists, the professionals engaged in the field of orthotics.
Individuals who benefit from an orthosis have sustained a physical impairment
such as a stroke, spinal cord injury, or a congenital abnormality such as spina
bifida or cerebral palsy. Corrective shoe inserts are often referred to as
orthotics. Pedorthics and Certified Pedorthic Practitioners called Pedorthists
are specialists in orthotics that deal with foot orthotics.
An orthotist is a clinician involved with assessment and/or evaluation, design,
fabrication of an orthosis or orthoses. A brace of this type is intended to
mechanically compensate for a pathological condition, so orthotists are
inherently required to be regulated by a certifying body. Licensure in some
states within the USA may also be required for these medical professionals. The
orthotist maintains certification through mandatory continuing education program
of the Board under which s/he is certified and adherence to the Board's Code of
Professional Responsibility is compulsory.
An important problem in the production of Orthotics, is a common Codification of
theese products, a common terminology in names, and finally common technical
specifications. A simple proposal for common codification of Orthotics has
intended by the Greek Orthopaedic Surgeon Dr. Harry Gouvas
UK
In the UK a brace of this kind is usually referred to as a caliper (sometimes
calliper in British spelling). Often the older type of leg brace is meant when "caliper"
is used, constructed of steel side bars and ring, with spurs which fit into a
metal tube in the heel of an adapted shoe or boot, and with leather straps and
bands around the leg to hold the splint in position. The straps can be secured
with velcro, but many patients prefer buckles. This type of caliper can either
be non-weight relieving or, by slight lengthening, made to relieve weight by
raising the heel of the foot away from the heel of the shoe or boot. These
splints have to be individually made by an orthotist or appliance maker closely
to fit the particular contours of the leg being supported.
UNITED STATES
A Licensed Orthotist is an Orthotist who is recognized by the particular state
in which they are licensed to have met basic standards of proficiency as
determined by examination and experience to adequately and safely contribute to
the health of the residents of that state. A BOC Certified Orthotist or BOCO is
an Orthotist who has passed the certification standards of The Board for
Orthotist/Prosthetist Certification and maintains certification through
mandatory continuing education program and adherence to the Board's Code of
Professional Responsibility. A Certified Orthotist (CO) is an Orthotist who has
passed the certification standards of the American Board of Certification in
Orthotics & Prosthetics.
A Certified Orthotist or CO(c) is an Orthotist who has met the highest standards
set by the Canadian Board for Certification of Prosthetists and Orthotists (CBCPO)
and maintains certification through mandatory continuing education programs and
adherence to the CBCPO's Code of Ethics.
A Certified Pedorthist or CPed(C) Canadian Certified Pedorthists are orthotic
and footwear experts. Pedorthists (C. Ped (C)) are one of the few healthcare
professionals trained in the assessment of lower limb anatomy and biomechanics.
With specialized education and training in the design, manufacture, fit and
modification of foot orthotics and footwear, Pedorthists help to alleviate pain,
abnormalities and debilitating conditions of the lower limbs and feet that if
left untreated could result in limited mobility.
CANADA
In Canada, to become certified as a pedorthist it is generally required that you
hold a bachelors degree in kinesiology followed by a post degree (diploma in
pedorthics from the University of Western Ontario). This is followed by a
rigorous internship program and a two part clinical and practical examination.
The clinician's duties include gait analysis, casting, measuring, fabricating
and fitting orthotic devices.
