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This was a question I got from a colleague. I get a lot a questions from colleagues, but not usually on that topic. Typically the questions are something like, which prefabricated foot orthotics do you use, which is the sort of topic that I know a lot about and not about foot creams which is a topic that I do not know a lot about! I not sure any recommendation from me on that sort of topic carries any weight.
I thought about it for a bit. With regards to the question on which prefabricated foot orthotics do you recommend, I typically answer that the best one is the one that has the design features that match the foot that it is needed for to get the effects that you want. Based on that there is no one best prefabricated foot orthotic. I also often say in lectures that a good clinician will not stick to just one prefabricated foot orthotic brand; they will have a range of brands with different design features so they can use the one that gives them the design features that they need. You need to be able to mix it up to get a clinical effect.
The more I thought about the foot cream question, then the answer probably should be the same. Different skins need different creams. A good clinician probably would not stick to just one brand, but have a range of brands at there disposal so they can use or recommend the one that gives the desired clinical effect.
That was pretty much the answer that i gave the colleague along with the recommendation that my advice on this topic should not carry a lot of weight.
What do I typically use clinically anyway? I like the 2 different concentrations of the urea creams, as I just get the impression (in the absence of good evidence) that they do seem to have a clinically affect on the most people. The urea concentration of below around 20% is better to moisturize the skin and concentrations of above around 20% are better at the helping get rid of the drier skin and getting up to 40% it appears to be more useful at the harder callused skin. So I mix it up, just like the prefabricated foot orthotic brands. I am in Australia, so I use the Walker’s brand of urea cream from Briggate Medical. It comes as a 15% and 25% concentration, so can choose the one the is needed to meet the clinical needs.
I still don’t get why they sought my advice on this topic ….
…or cuboid notch or cuboid pad or cuboid raise or cuboid elevation or Denton modification or Feehery modification or … it comes by many names. As well as having many names it is used for many reasons. There are lots of reasons and explanations given for what the purpose of it is and I not totally sure on any of them.
Some use it for cuboid syndrome, some use it to stop the foot sliding off the orthotic laterally, some use it to facilitate the movement of the center of pressure towards a high gear propulsion, some use it for … etc
The reason I raise this now is that it has recently been pointed out to me that things like a cuboid notch may not be placed in the right place. It got me thinking.
The cuboid does not “drop” and need to be supported in the sagittal place which is theoretically what a cuboid notch or pad does. Because the cuboid is part of the calcaneocuboid joint, as it “drops” it also everts (rotates). This could be interpreted as that if a cuboid notch or pad is indicated, then not only should it lift up the cuboid, it probably should also try to invert it. This means that our cuboid notch’s need to be moved more medially (but still on the lateral side of the foot orthotic shell), so they can try to invert the cuboid bone as well.
I know my anecdotal clinical experience has been I have had some awesome results and equally have had some absolute disasters where the cuboid notch has made the pain worse, so its mixed. I certainly do use adhesive felt padding on the foot as a treatment direction test to see if the design feature is indicated on a foot orthotic.
I now wonder if my dismal failures with this were becasue when I used the cuboid notch to lift up the cuboid, I was increasing the eversion force on the bone when I need to lift it up and increase the inversion force on the bone. All my cuboid pads are not being moved a little medially now, so lets wee what happens.
I think most of us have heard of the ‘too many toes sign’. This is when there are more than a few of the toes are visible on the lateral side due to an abduction of the forefoot when standing or walking.
This image from a screen grab of video that I did of a case I talk about during the Clinical Biomechanics Boot Camp could just about be considered as the “too many toes” sign:
Below is a screen grab of the video of the other foot. I like to call that one the “all the toes” sign rather than just the “too many toes” sign as all of the toes are visible laterally.
The key point in talking about this case was that it was the right foot that was the painful one and the left one with that severe “overpronation” was not the problem one. This means that the “too many toes” sign is not something to be necessarily worried about. What you need to be worried about is the forces behind the foot posture and be worried about them if they are high.
The “too many toes” sign is not really good terminology and is just something that clinicians may say to patient as part of a conversation. It is not a diagnosis. It is probably better to use the components of the Foot Posture index to put a number on the amount of forefoot abduction rather than just say too many toes.
The concept of peroneal muscle inhibition has both intrigued me and confused me, yet I do see it clinically and see the results, but the lack of objective data does trouble me. I started this discussion to get a better understanding of it. I am not sure it did.
The concept is that there is some sort of inhibition of the peroneal muscles, particularly the peroneus longus and the muscle does not work as it should. This “weakness” can lead to a range of symptoms from functional hallux limitus (and its compensations), increased risk for ankle sprains, lateral foot pain and maybe Achilles tendon pain. Muscle testing will show a significantly weaker peroneus longus. Its not clear what it is that leads to this inhibition which without objective data to consider that is a problem.
Typically with a mobilization of the proximal and distal tibiofibular joint, you can see an almost immediate return to the strength of the peroneus longus. I have certainly seen that plenty of times clinically and have no doubt about its clinical usefulness. However, I really struggle to come up with a coherent explanation of how the inhibition was caused and how the mobilization overcomes it. It you have something to contribute, please head over to Podiatry Arena and contribute your ideas in the thread on this topic.
In the early days of the Clinical Biomechanics Boot Camps we spent a lot of time on the supination resistance test and the concept of supination resistance, as the concept was so new to so many, but as time went by less time was spent on it as the test has become so widely used and quite pervasive when it comes to prescribing foot orthotics.
The test was first described by Kevin Kirby, DPM and we have done a lot of work on it with a number of studies exploring the concept. Along with that research I used clinically and we did a lot of practical sessions on it in the boot camps – all of this lead to what I think was a good understanding of it and just how useful it was to use clinically when it came to the prescribing of foot orthotics in clinical practice. I think those who did the clinical biomechanics boot camps did get to agree with me just how important that the concept was for the prescribing of foot orthotics and understanding pathology. There are a lot of threads on Podiatry Arena on the topic that get updated regularly.
The supination resistance test is simply a test to estimate just how much force is needed to supinate the foot and then applying that knowledge to how much force is needed to come from the foot orthotic. If the force to supinate the foot is high, then the force needed from a foot orthotic needs to be high. No point using a soft flexible foot orthotic in those with a high supination resistance as the orthotic is probably going to do nothing. If the supination force is low, then a soft flexible foot orthotic is going to be adequate. Using a rigid inverted type of foot orthotic in a foot with low supination resistance is probably going to sprain the ankle.
For our research we used a device that we built to quantify it but that device really has no practical use in clinical practice, so the use of the hands and manually estimating is adequate. There are some devices on the market, such as the Keystone that can be used to put a number on it.
What I used to like saying to people who were unfamiliar with the test is to just do it. Get a feel for it. Find those feet that are high or low and see how that might relate to the pathology that the patient has. Get a feel for how people with different levels of supination resistance respond to different foot orthotic designs. You soon start to see patterns.
I hope no one from parkrun reads this!
The parkrun is a weekly 5k run held in over 2000 locations at 8AM on a Saturday morning all over the world (COVID restrictions permitting). I have run a few and volunteered at a lot. I mostly do the one here at Mullum Mullum in Mitcham. These events do not go ahead without the volunteers
Why do I hope no one from parkrun reads this? I enjoy my Saturday morning interactions with the runners and walkers. I enjoy chatting with them. They have no idea of my interest and expertise in running, running injury and running shoes. I chat to them about what drives their shoe choices, how they managed with their injury, etc. It gives me insight into these issues. I do not generally give my advice. I like it that way. That is why I hope none of my new friends from the Mullum mullum park run see this post!
For those with an interest, please find a parkrun near you and give it a go at running it and helping out as a volunteer.
You may also find this book of interest:
Within physiotherapy there has been a big trend to distinguish between active and passive treatments with the general considerations that active treatments are better and the evidence does generally link better outcomes coming from the active treatments. Passive treatments are generally those that are done to the patient such as manipulations, massage, TENS and dry needling. Active treatments are those that the patients does to themselves such as exercises.
Given this division within physiotherapy, the question comes up as to if foot orthotics come under the active or passive category. I assume the answer to this could be based on someone’s preconceived biases as they want them to be a passive treatments when active treatments are seen as better. I do not think foot orthotics come under either category. Arguments could be made either way. There are other types of treatments that do not fit into one or the other category either, so why would you want to try and put them into one or the other? Is there any point trying? If you need foot orthotics, you need foot orthotics. If you don’t need them, then you do not need them. Does it matter if they are considered active or passive treatments?
I do agree that active interventions are probably preferable for a whole lot of reasons that I will not get into here. That does not mean that there is anything wrong with passive treatments (but there is a lot wrong with some of them and others do not have a lot or any evidence supporting them). For example, what is wrong with self massage for plantar fasciitis with something like a PediRoller? Passive treatments are probably better options during the acute phase of an injury.
What should it be called? I have long been part of the school that thinks we should be sticking with the posterior tibial tendon dysfunction name as that is the one that has mostly stuck and the problem was considered one of the posterior tibial muscle no longer being able to do its job – it just made sense. Two things are starting to change my mind:
It is the later point that is getting more and more attention. They are not the same thing. Posterior tibial tendonitis is an overuse injury in active healthy people. Posterior tibial tendon dysfunction is a progressive flatfoot deformity in older, often overweight adults. Two totally different sets of symptoms; two totally different populations; two totally different sets of clinical features …. yet some think they are the same thing on a continuum and some mix the two up and use the same treatment interventions. Nope.
I now think we should be calling posterior tibial tendon dysfunction either adult acquired flatfoot or progressive collapsing foot deformity to avoid the confusion and better reflect the underpinning pathological process. This terminology of progressive collapsing foot deformity is the name that seems to be being used more frequently in the most recent literature on this problem.
With all the travel I used to do for the Clinical Biomechanics Boot Camps I took to having ‘bacon and eggs’ for breakfast once in every city I visited and posting a photo on Facebook. It was always a source of discussion about the breakfast and the travel. After doing it for so many years, I paid one of my girls to scroll through my Facebook feed and collect all the photos and put them together on its own website for a bit if fun: Breakfast of Champions.
Sadly the COVID restrictions have put the breaks on the travel, except for local travel I have not been able to update the site much with any new international cities.
In my hands peroneal tendinopathy or tendonitis used to be a challenge. In the past I reckon I was close to a 100% failure rate in managing it. In the last 10 or so years I think I am now close to a 100% success in managing it. What changed? It was based on our research evidence. I talked about that in this blog post: Peroneal Tendonitis in Runners on my running research blog. It was pretty clear that almost everyone with peroneal tendinopathy had a lower than average supination resistance. That means the force needed to supinate the foot was low and as a consequence the peroneal tendons have to work harder, increasing the risk for tendinopathy. This also means that those with it need lateral wedging under the heel to decrease the loads in the tendon. That wedging actually leads to a substantial reduction in the forces that the tendon is subjected to, so hence the lateral wedging is a very and often is dramatically effective to manage peroneal tendonitis.
Yes, lateral wedging does try to pronate the foot more, but never had a problem with doing that. It did take a mindset change to get confident to start doing this 10 or more years ago, but I have not looked back. This is a perfect example of research informing and changing clinical practice.
This also means that a typically arch supporting medially wedged foot orthotic is going to increase the load on the peroneal tendon and is not going to be indicated. This also explains why I had almost a 100% failure on managing this in the past.
Also, of course, we do the usual load management approaches to this tendon once that reduction in load on the tendon with the wedge is done.