Functional versus Accommodative Custom Orthotics

I recently saw a commercial that was advertising a ‘Dr. Scholl’s Custom Fit Orthotic Insert Kiosk’ and I wondered, how exactly they were custom fit if there were only several inserts to chose from? It started me thinking about orthotics and how often the general public makes mention of them, but how little they generally know about their specifics. I wanted to take the opportunity, over the next several weeks to discuss what custom orthotics are and what you would be getting when you purchase something over the counter or from a Kiosk.

As Podiatrist we prescribe patients custom molded orthotics for a variety of foot ailments, but often, if we feel as though their condition would benefit from an over the counter orthotic insert, we start there. The one thing all patients and members of the general public can agree on is that custom molded orthotics can be expensive and are often uncovered by insurance companies. As Podiatrist’s we are not in the business of bankrupting our patients and thus if we feel that an over the counter orthotic would be sufficient enough to help your current condition, that is our first recommendation. However, there instances where we know that custom molded orthotics are the best option for you and the one that will provide the greatest relief, so in some circumstances they are our first recommendation.

There are two main types of custom molded orthotics that we prescribe, known as Functional and Accommodative orthotics. What people typically think of when they think of orthotics are those that are functional; coincidentally that type is the most often prescribed.

The general objective of any functional orthotic, regardless of the condition it is prescribed for, is to allow the foot to sit in as neutral a position as possible. By neutral position, what I’m referring to is the position of your foot where the tendons and ligaments surrounding the ankle are aligned in their most advantageous position, allowing the foot to function as “normally” as possible while eliminating compensation for any abnormality. In many conditions the orthotic is indicated to block abnormal motion of the foot by bringing the ground up to the foot (via the orthotic material) helping to decrease pain and deformity. To show the diversity of conditions for which functional orthotics can be utilized, a very limited list of conditions is detailed below:

Hallux limitus/rigidus
Pes plano valgus (collapsing/flat foot)
Cavus foot (high arched)
Limb-length discrepancies
Bunion deformities
Plantar fasciitis
Neuromas
Neuromuscular conditions

The objective of an accommodative orthotics is to accommodate the foot rather than to place the foot in a neutral position. These are often utilized in patients who have rigid conditions where the foot would not benefit from repositioning. Therefore, accommodative orthotic devices are prescribed for patients who need pressure alleviation at areas of high-pressure, such as diabetic patients with areas prone to ulceration. In such situations realigning the foot via the use of functional orthotics may do more harm to the patient than good.

Regardless of whether the functional custom orthotic or the accommodative function orthotic is utilized, they are both manufactured from a cast and/or digital image of your foot. Those casts or images are sent to a laboratory specializing in orthotic manufacturing and the custom orthotics come to life with adherence to specific manufacturing instructions from your Podiatrists. Custom orthotics are exactly that: custom to your foot through the cast or images sent to the orthotic laboratory. As we’ll discuss in the coming weeks, anything purchased over the counter cannot be custom if there are only a few varieties to choose from and if your “foot images” were not sent to a specialized orthotic laboratory for manufacturing of your orthotic devices from those images.

In efforts not to overwhelm you with the wealth of information regarding orthotics, we will stop here for this week. Next week, we will tackle the topic of over the counter orthotics versus those that are custom molded; how they differ and what those over the counter ‘custom fit orthotics’ really are.

Pretty in Pink…Nail Polish??

Summer is essentially here with the heat we’ve been having recently, thus men and women alike are flocking to nail salons hoping to perfect their toenails for sandals and peek-toed heels! This week we’re taking the opportunity to remind you of some ‘salon smart’ tips that will help you select a salon that’s clean so you receive that pedicure you’ve been craving, while keeping your risks of infection low!

1. Assess the salons cleanliness: Look around when you enter a nail salon and check to see if they have bottles of cleaning products near their pedicure soaking tubs. Are they cleaning out the tubs after each client? Soaking tubs are the areas in a salon that carry the highest risk of infection, so use caution! Have they autoclaved their tools between each client? The only way to ensure that nail tools are completely sterilized is through the use of an Autoclave (those little “hot boxes” where tools are placed between each client). Without Autoclave sterilization the tools are only “clean,” and may have lingering organisms present.

2. Purchase your own set of tools: Many salons provide clients the option of purchasing their own “nail tools,” for which you are the only client using those tools. Investing the extra few dollars on that first visit will provide you a decreased risk of infection and peace of mind, knowing that only those tools have touched your feet. You no longer need to worry about who’’s toes were being worked on before yours, and what “bugs” may be passed from them on to you.

3. Ask the salon personnel NOT to push back your cuticles: The nail cuticle is one your body’’s protection mechanisms for keeping bacteria out. By pushing the cuticle back, you open up the possibility of infection, as bacteria can now enter underneath the cuticle. Interrupting the natural function of your cuticles combined with un-sterilized tools and dirty soaking tubs is a sure bet for infection!

4. Give your toenails a rest: Frequently taking off nail polish and allowing the nails to “breath” helps prevent extra moisture from building up under the nail, subsequently decreasing your risk of infection by bacteria or fungus. In the winter months when sandals are infrequently worn, try to go without nail polish as much as possible. In the summer, when you know you won”t be on vacation or won”t need your nails looking “pretty in pink” for a certain event, take the polish off and give your toenails a break.

5. If you”re diabetic, pedicures are NOT recommended: As mentioned above, dirty tools, soaking tubs, and interrupted cuticles all combine to create a high risk for infection. The risk of infection from a pedicure is the same for clients with and without diabetes, but in the diabetic, the healing potential can be significantly decreased. Due to the nature of diabetes and the course it takes within the body, blood supply to the toes may be decreased, and without adequate blood flow, the cells in your body that fight infection are less likely to reach the site. This can lead to an infection that, in severe cases, runs up the foot and leg and if not caught early and treated aggressively can lead to loss of toes! In addition, healing potential for diabetics is decreased and for the same reasons infection takes a greater toll; the cells in the blood needed for wound healing are less likely to reach the areas where they are needed. In short, if you”re diabetic, it’’s wise to avoid pedicures at a salon. Instead, do your own pedicures at home where you can be sure everything is clean and leave your cuticles intact.

Hopefully these tips will pop into your head as you contemplate your next pedicure. It’’s important for feet to look nice for the summer months eliminating embarrassment with sandals where toes are exposed, but it’’s more important to avoid infection and its long-term complications!

How Did You Get Osteomyelitis?

Last blog entry gave a very brief overview of some of the more common imaging studies that Podiatrist’s tend to order to help them confirm their diagnosis. It reading that blog, your interest may have been peeked when the idea of bone infection was introduced, as it was discussed under several of the imaging modalities since bone infection can be captured in various ways. This week, I hope to indulge your newfound interest and provide some insight into the topic of bone infection. This topic is not an easy one to broach, as there are many questions when dealing with bone infections that must be answered. The why and the how of bone infection in a patient can sometimes be very clear-cut and in other patients, can be quite a mystery. The key, however, in treating bone infections is prompt diagnosis!

Let’s break it down a bit:

What is a bone infection? Bone infection, more commonly referred to as Osteomyelitis (Osteo = bone; meylo = marrow; itis = inflammation) is exactly as it sounds. Infection, much the same as would present in the skin, invades into bone allowing bacteria to thrive and wreak havoc. The severity of the bone infection depends on a number of variables, some of the more important of which are: how much bone is infected, the condition of the surrounding soft tissue structures, if the infection has traveled to other areas of the foot and leg, and the health status of the infected patient.

Who gets bone infections? Patients who are at a higher risk include those who have suffered an open fracture (one where the skin was opened upon fracture of bone) and those who present with chronic (long standing) open and infected foot ulcerations/wounds. However, anyone can suffer from osteomyelitis. In reactivated forms of osteomyelitis, bone infection occurred years ago but the infection suppressed by the body; secondary to trauma to the previously infected area, reactivation can occur.

When should you become suspicious of a bone infection? Those patients who should have the highest index of suspicion for a bone infection are those patients who are at a higher risk (i.e. open fracture patients and those with long standing infected wounds). If you are being treated for a long-standing non-healing wound, additional imaging studies may be recommended to rule osteomyelitis in or out. In a healthy patient signs of infection include redness, swelling and heat in the suspicious area, but in those patients with chronic wounds and a compromised immune system, such as Diabetics, those same symptoms may never present themselves.

Why is early recognition key? Early recognition is key so that initiation of treatment is prompt. The earlier bone infections are diagnosed, the better the treatment outcomes. The worry is that bone infections will continue to spread to adjacent bones and additional soft tissue structures causing larger infections that are more difficult to treat with antibiotics alone.

Where is the most common location in the foot and ankle? The most common location of osteomyelitis in the foot is underneath the metatarsal heads. The metatarsal are the long bones of the foot that connect to the toes. The location of the metatarsal heads is in the approximate area of the fat-pad of the forefoot. This area is most commonly affected because the metatarsal heads are under high pressures throughout gait.

How do we treat bone infections? Treating bone infections is very tricky and among other things, Podiatrists must carefully consider each patient before deciding on a treatment regimen that is best for that particular patient. Almost all patients will be placed on antibiotics, but depending on the severity of the infection depends on if those antibiotics will be administered in pill form or via an IV (intravenous) infusion. If you have a bone infection, expect to be on antibiotics for 4 weeks at the very least, but typically longer courses are required. If a bone infection has become so severe that antibiotics are only effective in keeping the infection at bay but will not eliminate the bacteria from the body all-together, surgical intervention is usually necessary. Surgery entails finding the source of the infection and any collections of infectious fluid and draining them, in addition to washing-out all the surrounding soft tissues and removing any bone that is dead/dying.

Osteomyelitis can be a scary and tricky diagnosis to face, but conversations with your Podiatrist (should you be diagnosed) can be very informative and will lead you towards the most appropriate treatment path with the greatest outcome for healing!

Imaging, Imaging and More Imaging!

As Podiatrist’s we order A LOT of imaging studies for our patients. Such studies include x-rays, MRI’s, CT Scans, Bone Scans, and Ultrasound to name a few. It may sometimes seem unnecessary and annoying because treatment is occasionally postponed until the results of such studies are received, but I assure you, they have their purpose. This week, the intent is to briefly describe some of the imaging studies we order, why we order them and how they differ from each other. However, it should be understood that we do not arbitrarily order imaging studies to help us come up with a diagnoses, but rather we use them to confirm our suspicions of a diagnosis.

X-rays: This is typically the first imaging study that will be performed by your Podiatrist. X-rays primarily capture the bones of the foot and ankle and for this reason, they are typically ordered for fractures, bunions, hammertoes, and any pathology that may disrupt the bone including diffuse bone infection, bone tumors, gout and arthritis to name a few. They also allow us to take a closer look at the position of the bones during stance, providing a snapshot of how your foot functions during gait (walking). X-rays, although they can’t specifically convey information about the soft tissues (muscles, ligaments, tendons) they can show swelling, which most often correlates with a clinical picture. Finally, they can show calcified vessels: blood vessels in the lower extremity that have become hardened and thus indicate poor blood flow to the lower extremity. Limitations to x-rays, as mentioned above include soft tissues structures, which need further imaging studies for complete evaluation. In addition, x-rays have a lag time in recognizing stress fractures and acute (early) bone infection. For a plain x-ray to show either of those two pathologies, the pathology needs to have been present for about 10 days; long enough for significant bone destruction (50%) to be visualized on x-ray. For that reason, with a high clinical suspicion of either of those two pathologies, additional imaging studies are typically performed.

MRI’s (Magnetic Resonance Imaging): If we want to get a better picture of soft tissue structures including muscles, tendons, and ligaments in the lower extremity, MRI’s are a good option. MRI’s have the ability to hone in on inflammation within or surrounding a tendon and clearly show ruptures of such structures. They focus less on bone pathology when referring to fractures (CT’s are more accurate), but they are superior to CT scans in diagnosis bone infection (osteomyelitis). The reason being that they provide excellent visualization of the medullary canal of the bone (the central area where bone infection tends to migrate), and thus help Podiatrists determine how far the infection has spread and how aggressive their treatment regimen needs to be. Finally, they are the best option diagnosing pathology between bone and soft tissue, where it needs to be determined if bone pathology has spread into adjacent soft tissues and vice versus. The only downside with MRI usage is that, should a patient have any metal or stainless steel anywhere in their body, these studies cannot be performed as they interact with the magnets within the MRI machine.

CT Scans (Computerized Tomography): These scans are excellent for visualizing bone to a greater degree than standard x-rays can show us. Often CT Scans are ordered for evaluation of complex fractures such as Lisfranc fractures and calcaneal fractures. They can more accurately show fractures too small to be visualized on plain x-ray in addition to helping to determine the amount of joint surface involved in the pathology. CT scans can also be used in diagnosis of bone infection, but MRI’s are typically a better option as they can more accurately capture the medullary canal. CT scans can be used in patients with metal or stainless steel implants, thus are a good alternative for patients who can not undergo MRI evaluation.

Ultrasounds: This imaging studying is becoming more and more popular among Podiatric Physicians, whereby diagnosis of various pathologies can be made through its use. The test takes little time, making it more convenient for the patient in addition to providing quick results to you Podiatrist. Ultrasounds are very useful for tendon pathology, meaning any deformity or abnormality in a tendon, such as rupture, tear, or inflammation surrounding a tendon, which indicates aggravation of the tissue. These studies are also becoming more popular for use in diagnosing neuromas (inflammation of nerve tissue in the web-spaces) and have provided use in guiding injections of the foot for more accurate medication placement.

Although it can seem burdensome, imaging studies do help us confirm our suspected diagnoses and are often necessary for treatment to begin, so we appreciate you taking the time to have them completed per our request. The hope is that you now have a greater understanding of each of the imaging modalities discussed above, and can thus understand why we request them to be performed. Certainly, each type of imaging study discussed above encompasses a broader range of uses, but those discussed this week are the primary reasons for viewing in the foot and ankle.

It’s Really Not a Bunion?

A bunion and HL/HR are two different conditions and although patients often confuse them, it’s important when presenting to a Podiatrist that the conditions are separated from each other, as etiology and treatment different.

Hallux limitus is a restriction or limitation to motion of the great toe joint that results mainly from biomechanical abnormalities of the foot. As the condition, progresses the joint motion becomes so restricted that motion at the great toe joint ceases all together, resulting in a condition called hallux rigidus. After a complete evaluation of the involved foot, your Podiatrist will discuss all treatment options for HL and HR with you, most often suggesting treatment options that are first conservative. We mentioned several of those options last week including orthotics, joint injections and padding of the toe to decrease pressure in the area of concern. When conservative treatments have been attempted and exhausted without resolution of symptoms including pain and discomfort in the great toe joint, surgical options can be explored.

As with any surgical procedure, your Podiatrist will review your x-rays, re-examine your foot and recommend a surgical procedure most appropriate for the status of your HL/HR condition that aims to decrease your current level of pain. In treating HL/HR there are 3 larger categories of surgical procedures that we will briefly discuss; the first two options, in order to decrease your current level of pain, aim to decompress the joint to accomplish this goal. Decompression allows for the creation of a larger space between the two bones that make up the great toe joint therefore, allowing greater motion and less jamming between the two. You and your Podiatrist will discuss the options and determine which is the best option for you.

1. Joint Cleaning: The first procedure attempts to enter the great toe joint and clean up the area between the two involved bones. Any inflammation within the joint is removed, any boney spurs are shaved down and smoothed off and the joint is closed. This procedure is typically reserved for patients in the early stages of HL/HR development and often provides great relief. Removing any spurs and inflammation decompresses the joint, allowing for greater motion. Recovery is generally short, approximately 2-4 weeks, as only soft-tissues need to heal before activity can be resumed.
2. Bone Cutting Procedures: This category encompasses several different types of procedures, but all accomplish decompression of the great toe joint with the result of greater motion and decreased pain by surgically cutting one or both of the bones making up the great toe joint. The procedures aim to lower and slightly shorten the 1st metatarsal to create a larger joint space. Be aware, fixation including pins and screws may be utilized! These types of procedures are typically reserved for patients with more advanced HL and recovery time is typically longer versus joint cleaning procedures (closer to 6-8 weeks), because the surgery is more involved and needs to allow significant time for the bone to heal.
3. Fusion: A fusion procedure of the great toe sounds just as it is; the great toe joint is fused whereby motion at the joint is surgically eliminated with the use of pins and screws to hold the toe in its desired position. As we mentioned last week, if there is no motion, there is no pain! This procedure is reserved for “worst-case” patients and those who have unbearable pain at a young age and is considered a definitive procedure. Recovery is longer than even the bone cutting procedures to ensure that complete fusion has take place before weight bearing can begin.

As with any surgical procedure the risks and benefits should be considered and discussed with your Podiatrist before any decisions are made. Complications with any of the HL/HR procedures described above can include infection, scarring, recurrence of deformity, and transfer pain among others, although the risks of any such complications are minimal. The object of both conservative and surgical treatment options is to decrease pain and increase motion at the great toe joint while keeping you on your feet!