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Description: The OPMA has taken the past 10 years of articles, media clips, foot health facts and general public information and bundled them in year groupings for ease of reference. There are 3 additional parts to this series.
Foot Health Advice 1999-2001 Foot Health Advice 1999-2001 Contents Achy Breaky Feet ................................................................................................................. 2 Osteochondritis of the Metatarsal Head ............................................................................. 5 Beauty 911 You Ask the Experts ......................................................................................... 6 Morton s Metatarsalgia......................................................................................................... 7 Orthotic Referral Criteria...................................................................................................... 8 Laser Foot Surgery............................................................................................................... 9 Plantar Fasciitis ...................................................................................................................11 How to Buy the Best Shoes ................................................................................................13 Morton s Neuroma ...............................................................................................................15 1 Foot Health Advice 1999-2001 Achy Breaky Feet Michelangelo called the foot a masterpiece of engineering and a work of art but it seems the design was not built to last -- at least not on the asphalt on which most of us walk. Toronto -- I have orthotics but I never wear them says a woman who owns a boutique and is on her feet all day. I only wear them when I jog says another woman an exercise delinquent who has put her running program on hold. Neither wants her name used. They are footcare failures orthotic dropouts. Orthotic devices are custom-made plastic shoe inserts designed to control extra motion during walking they re supposed to keep weight off parts of the foot that receive most pressure. The theory is that a lopsided way of walking or ill-fitting shoes can cause all manner of foot problems -- callouses bunions hammertoes arch and heel pain. Once you ve got orthotics you realize everyone has them says Toronto travel agent Brian Stein. His problem was typical As a result of plantar fasciitis inflammation of the connective tissue on the bottom of the feet walking was unbearably painful for the first 20 minutes of the day. Mr. Stein saw a podiatrist paid 600 for orthotics and now they never leave my shoes. But for every Brian Stein there is someone who pays for orthotics but seldom uses them or uses them only for certain activities such as power walking. Many women find them too bulky for dressy shoes. Provincial health plans do not pay for orthotics but many private plans cover them. For the uninsured orthotics add up to hundreds of dollars. Not surprisingly foot doctors often prescribe orthotics to people with private insurance while others are directed to off-the-shelf aids. The question is how many people really need orthotics It s not that foot problems are uncommon They are said to affect more than 80 per cent of the population. Millions of abused calloused deformed feet are marching through life in pain and discomfort. Michelangelo called the foot a masterpiece of engineering and a work of art but it seems the design was not built to last at least not on the asphalt most of us walk on. We are born with fat pads on the bottom of our feet but the more we walk -- or jog which triples the amount of pressure on the foot -- the faster they wear out. There is something perverse about nature giving us tenacious fat everywhere but the place we need it -- on our feet. Foot problems explode in middle age of course but even younger people are vulnerable especially if they jog. Running after 40 is unrealistic says Toronto podiatrist Bruce Ramsden president of the Ontario Podiatric Medical Association. The feet can only take so much punishment. Weight gain which usually comes with age also contributes to foot problems he adds. Every pound of weight gained means 2 more pounds of additional pressure on the feet. Women fashion martyrs pay a severe price for wearing high heels which squeeze the foot into a too-narrow toebox an unnatural position that can cause bunions and hammertoes in women predisposed to those conditions. Heels also change the centre of gravity putting strain on the knees and spine. Men suffer too. According to the magazine Men s Health 90 per cent of American men suffer from foot pain but only 10 per cent seek treatment. Are orthotics the answer Many podiatrists continue to pare down callouses and remove corns but their most touted cure-all is orthotics. The custom-made inserts have become like Prozac for the feet. They are supposed to prevent foot problems by propping up the arch and realigning the foot as it moves so that excessive weight doesn t fall on the collapsed and thinning pads on the balls of the feet. 2 Foot Health Advice 1999-2001 And they don t just work on the feet Orthotics are supposed to correct or prevent problems in the knees back and hips. Knee problems are often caused by foot problems notes Dr. Ramsden. The culprit is pronation. While some people supinate or walk on the outside of their feet most people tend to pronate or roll in towards the arch or big toe. Pronation is the root of all evil the major cause of foot problems podiatrists see says Toronto podiatrist Hartley Miltchin executive director of the Canadian Podiatric Medical Association. Pronation can cause everything from corns to knee pain. If your car s front-end alignment is out of whack the tires will wear down at one side he explains. Fix the alignment and everything wears evenly. But does every pronator need a 500 prescription orthotics Overprescription is a touchy subject says Toronto Sports Medicine expert and medical doctor Grant Lum. There are people out there who will prescribe orthotics for just about anything. MDs podiatrists chiropractors and physiotherapists can prescribe orthotics Dr. Lum explains. Some have a financial stake in manufacturing the devices others profit from making the plaster casts or the computer assessment a diagnostic procedure in which the patient stands on footpads with sensors that produce a computer image of their feet. Although computers are widely used in diagnosing foot problems the Canadian Podiatric Medical Association says they have their limitations. The association insists that a plaster mould of the foot also be taken. The mould is used to make the orthotics and it gives the most accurate reading of the problems. Despite the rush to prescribe orthotics off-the-shelf products are selling vigorously. According to Barrie Riome Dr. Scholl s Canadian director of foot-care marketing there was a 20-per-cent increase in consumer spending in l988 for all brands of foot-care products. This growth rate puts foot care among the fastest growing categories in the health-care industry Mr. Riome says. Most foot specialists admit off-the-shelf products have their place. Dr. Scholl s DynaStep inserts a horseshoe shaped pad developed by podiatrists to cradle and align the foot while it moves can help some people with mild problems notes Dr. Miltchin. Over-the-counter heel cushions will sometimes alleviate temporary heel pain adds Dr. Ramsden. Insoles such as those made by Birkenstock which must be fitted are recommended by the Foot Care Centre at Toronto s Women s College Hospital. When singer song writer Nancy White was planning a walking trip in France last year she went to see Peter Wons the chiropractor owner of The First Step a Birkenstock store in Toronto. Her problem was not severe just feet that ached after long walks and shoes that never seemed to fit properly. He had her try silk-lined cork inserts of various shapes until she found one that was comfortable. I can t believe I m saying this but it was like magic -- even after walking long distances I didn t need to take my boots off. Other inserts that are not custom-made are also sold by podiatrists. Sometimes I give my patients customized but not prescription devices notes San Francisco podiatrist Arlene Hoffman who teaches at the California College of Podiatric Medicine in San Francisco. One example a pad that helps alleviate pain on the ball of the foot. When the fat pads thin the metatarsal heads get irritated then if the foot is not ideal too much force is put on a specific metatarsal head instead of evenly spread on all five she explains. When it comes to happy healthy feet what you wear on them is more important than orthotics and other devices. 3 Foot Health Advice 1999-2001 Dr. Hoffman s advice is standard Buy shoes only after you have been on your feet awhile and make sure the end of the longest toe is at least a quarter of an inch from the end of the shoe. The shoe should allow you to wiggle all your toes. Avoid high heels says Dr. Miltchin. Stuffing feet into the pointy toes of high heels is comprable to putting five cars into four parking spaces. Most women s shoes do not accommodate the triangular shape of most women s feet which are wider at the toes narrower at the heel. But what about how we walk Marion Harris is the director of the Feldenkrais Centre in Toronto which teaches people how to change habitual movement patterns so that the body is more balanced and less stressed. She says that shoes and orthotics can be helpful but they should be used as an aid not an extension of our bodies. They re no substitute for healthy well-organized posture and movement she says. If you re always using a support then nothing is allowed to change she says. We should look at what s happening in the hips the back even the neck. she points out. Many of us have been instilled with the idea that good posture means standing straight with the chest elevated and the shoulders held back. This puts too much weight onto the balls of your feet says Ms. Harris. She suggests an exercise Walk slowly backward a few steps and notice the position of your body. Then walk forward bringing these new sensations of ease into your forward walk. Better shoes more awareness shoe inserts -- these are giant steps away from foot neglect and abuse. People with foot problems don t have to suffer says Dr. Miltchin. Even without pricy orthotics the walking wounded have come into their own. Stretching It You should stretch and strengthen your feet like you do your arms notes exercise physician Grant Lum. The admonition applies to everyone -- not just athletes. Such conditions as arch strain often occur because people do not stretch. He and other experts recommend the following exercises. Lean toward the wall with both hands. Bend one knee and stretch out the the other leg with the ball of the foot firmly on the floor. Move outstretched heel up and down stretching the leg. Switch legs. While sitting straighten knees and raise the feet. Circle each foot 10 times to the right then 10 times to the left. Point the toes then flex the feet. Standing raise yourself on your toes hold drop back down. Do 10 times. Anatomy of the Foot Each part of your foot plays a role in supporting you. Together these parts form a working system that results in movement. BONES form the framework that gives your feet shape. JOINTS are the meeting points between bones that allow your feet to bend and move. MUSCLES are bundles of fibers that power movement. TENDONS are cords of tissue that attach muscle to bone. Jacqueline Swartz LIGAMENTS are similar to tendons and hold bones together forming joints. Special to The Globe and Mail NERVES relay signals between your brain and your feet. Source Dr. Scholl s Podiatry Information Library BURSAS are sacs filled with fluid that help reduce friction. January 26 1999 by Jacqueline Swartz 4 Foot Health Advice 1999-2001 Osteochondritis of the Metatarsal Head Recognizing the symptoms of Freiberg s Disease In 1922 Dr. Albert Freiberg described a pathological condition of the foot which affects the head of the second metatarsal. Freiberg noticed that this condition now called Freiberg s disease was most evident in tennis players most likely due to trauma. Thirteen years later Freiberg discarded his theory on trauma as a possible cause. In subsequent years many individuals hypothesized that Freiberg s disease was probably caused by juvenile osteochondritis. A Growing Process Understanding Freiberg s disease requires knowledge of the ossification process in the metatarsal bones of the feet. Each of the metatarsals are ossified from two centers metatarsals 2 through 5 have one center for the body of the metatarsal and another for the head the first metatarsal has one center for the body and one for its base. Ossification begins in the center of the body during the ninth week of life. The center for the base of the first metatarsal appears in the third year of life the centers for the other metatarsal heads appear between the fifth and eighth year of life. Throughout adolescence the epiphysis and metaphysic are separated by a narrow epiphyseal plate. The epiphysis ossifies to the metaphysic between 18 and 20 years of age. Epiphysitis If during this time (when the epiphysis is still present) the blood supply is interrupted by trauma epiphysitis occurs. It is believed that a micro fracture happens at the epiphyseal plate since it is somewhat calcified and vulnerable. This fracture could be due to endocrine disorder trauma or infection. The exact etiology is still debatable and somewhat unclear. Trauma in the second metatarsal seems to be a plausible cause since it is usually the longest metatarsal in the parabola and excessive stress may be noticeable. In females this condition is most often located in the second metatarsal. Epiphysitis leads to aseptic necrosis in turn leading to decalcification at the metatarsal head. Degeneration ensues continuing for about one year from onset this is then followed by regeneration that leaves osseous hypertrophy of the bone. Loose bodies are often found in the joint along with crepitus. Symptoms and Treatments Early signs of this condition can be detected with x-rays they will show a rarefaction of the metaphysic with sclerosis of the epiphysis. The distal end of the affected metatarsal is flattened the shaft is hypertrophied and the head may appear somewhat fragmented. If diagnosed early treatment should involve reducing stress on the metatarsal. Padding of varying degrees can help to balance or eliminate stress under the affected metatarsal. Physical therapy can also attenuate the discomfort associated with this condition. If extensive osteophytic changes result and deform the affected metatarsal it can also impinge on and affect the adjacent metatarsal. Surgical intervention may be necessary to remodel the joint. Surgery should aim to keep the metatarsal parabola intact to avoid transfer lesions. An Elusive Diagnosis Many patients suffering from Freiberg s disease are asymptomatic. Often the diagnosis is made as secondary to x-ray findings for another manifested foot ailment. When a patient complains of pain in the second metatarsal Freiberg s disease should be considered as a possible underlying cause. Metatarsal phalangeal joint crepitus and pain are symptoms that combined with x-rays can usually lead to this diagnosis. Hartley Miltchin DPM Canadian Footcare Practice June 1999 Vol. 4 No. 1 5 Foot Health Advice 1999-2001 Beauty 911 You Ask the Experts Question What Is nail fungus How does one know if one has it and how Is it treated Catherine Toronto Answer Fungus Is a contagious organism that lives and thrives in warm dark moist environments explains Dr. Hartley Miltchin executive director of the Canadian Podiatric Medical Association. After people bathe they tend to dry the tops and bottoms of their feet but not inbetween their toes so a bit of moisture may stay there. Then they put on their socks (a warm dark moist environment) and the fungus proliferates. Untreated it ll travel to the nail. You may notice some discolouration and perhaps brittleness or thickening. Once in the nail the fungus can reach underneath to the nail bed (the soft skin area) where it will move toward the cuticle and then to the root of the nail so every time the nail grows it ll grow with the fungus in it. Over time the fungus can spread to other toes and through touch even to the finger nailsl Speaking of fingernails artificial ones can also lead to fungus. If moisture has been trapped between the nail plate and the artificial nail a fungus can develop warns Debbie Krakalovlch of The Nail Shoppe In Toronto. So how is fungus treated If It s caught early enough we can use a topical preparation says Dr. Miltchin. If it s gotten to the root then the only way to treat it is Internally. Can you contract any type of disease just from shaving your legs Unfortunately shaving or waxing could cause the skin disease folliculitis (an inflammation around the hair follicles that causes red bumps) or pseudo-folliculitis another name for ingrown hairs says Dr. Catherine Zip of The Dermatology Centre in Calgary. The closer the shave the more likely you are to have problems she says. Problem prevention Use an electric razor [not as close a shave] shave with the direction of the hair and use an alphahydroxy acid containing an emollient after shaving. OuchI Won t that sting It can [but only] momentarily. Serious diseases such as hepatitis C and AIDS are carried in the bloodstream and can be transmitted by coming into contact with someone else s blood so don t share razors with anyone. FLARE Magazine OCTOBER 1999 October 1999 by Hartley Miltchin D.P.M. 6 Foot Health Advice 1999-2001 Morton s Metatarsalgia Question What is the treatment of choice for Morton s metatarsalgia Ravinder Ohson MD Hamilton Ont. Answer While metatarsalgia may refer to generalized pain in the forefoot Morton s neuroma presents as an acute or burning pain in the ball of the foot. Often patients feel the need to remove their shoe and massage the foot between the third and forth metatarsals. To elicit the symptoms (from dorsal and plantar) you can grasp the foot from the medial and lateral sides and gently compress while using the other hand to gently pinch the area between the metatarsal heads. This would differentiate pain of the metatarsal head (which may be capsulitis) or pain on the dorsal aspect of the metatarsal shaft (which could be periostitis or a stress fracture). Neuromas are due to pronation which results in impingement of the common digital nerve. Properly made orthotic devices correct the problem ice and massage may provide temporary relief. Often people who are wearing slip-on dress shoes are relieved by switching into soft-soled walking shoes or running shoes. A metatarsal pad usually doesn t help much. For more resistant cases an injection of anti-inflammatory medications works well. I prefer a dorsal approach with a 27-gauge 1-1 4 needle and combine 0.5 mL of 2% lidocaine HC1 (Xylocaine) plain and 0.5 mL of 0.5% bupivacaine HC1 (Marcaine) plain with 0.5-1.0 mL of a corticosteroid (I use Celestone Soluspan) and about 0.2 mL of cyanocobalamin. The vitamin B12 acts as a sclerosing agent on the neuroma. Occasionally we ll have to use a subsequent injection a month later (up to a maximum of three). Surgical excision is considered only as a last resort. In my 20 years of experience only about 5% of cases have needed surgical treatment. Suggested Reading An Atlas of foot surgery (Vol. 1). 0. A. Oak Park lllinois.Mercado Press 41-42. Valmassey RL. Clinical biomechanics of the lower extremities. St. Louis Missouri Moseby-Year Book Inc. 1996 74-75. Lloyd Nesbitt DPM Toronto Ont. REFERENCES 1. Bull RC. Handbook of Sports injuries. McGraw Hill. 1999 800-808. 2. Subotnick SI. Sports Medicine of the Lower Extremity. Churchill Livingstone 1999 465-467 PATIENT CARE CANADA VOL.10. N0.8 AUGUST 1999 February 2000 by Lloyd Nesbitt D.P.M. 7 Foot Health Advice 1999-2001 Orthotic Referral Criteria Question What criteria should be used in deciding to refer a patient for orthotics Cathy Risdon MD Hamilton Ont. Answer Orthotics are often required when symptomatic treatment modalities have provided only temporary relief of foot pain as a biomechanical imbalance may be the etiological factor. Overuse syndromes of the lower legs or knees often result from imbalanced feet and may respond to orthotic control. Calluses are a tip-off to a foot imbalance. Pronation causes calluses inferior to the second or third metatarsal heads and medial to the hallux. With rigid high arches they appear inferior to the first and fifth metatarsal heads.(1) Also examine the patient s stance and gait. A high arch may flatten when bearing weight which would be another indication for orthotics. Podiatrists recommend a biodynamic device made from a neutral subtalar joint position plaster cast. This guides each foot through the various weight-bearing portions of the gait cycle to promote a biomechanically efficient movement pattern. The result should be a reduction of symptoms from overuse syndromes(2). Note that foam impressions of the foot or so-called computer orthotics may result in the patient receiving no more than a modified off-the-shelf premade device which usually does not provide precise biomechanical control. Lloyd Nesbitt DPM Toronto Ont. REFERENCES 1. Bull RC. Handbook of Sports injuries. McGraw Hill. 1999 800-808. 2. Subotnick SI. Sports Medicine of the Lower Extremity. Churchill Livingstone 1999 465-467 PATIENT CARE CANADA VOL.10. N0.8 AUGUST 1999 August 1999 by Lloyd Nesbitt D.P.M. 8 Foot Health Advice 1999-2001 Laser Foot Surgery When the carbon dioxide radio-frequency-excited surgical laser was introduced in Canada in 1983 everyone thought it would become the treatment of choice for foot problems. The laser is an effective tool but it is not a panacea for foot problems its best applications are for treating verrucae porokeratosis and ingrown nail. Verrucae Because these lesions can be stubborn treatment of verrucae is frustrating for both patient and practitioner. Warts used to be treated on a repetitive palliative basis or removed surgically. Though dermatologists still use liquid nitrogen on plantar warts the patient may still wind up in a podiatrist s office after several treatments. The most effective form of treatment for warts seems to be the CO2 laser. Advantages Mosaic verrucae or single lesions can usually be vaporized with only one treatment. There is no need to inject a local anesthetic directly into a lesion the posterior tibial block or dorsal mayo block suffices. Because it is so precise the laser cauterizes small blood vessels there is less bleeding than with traditional surgical approaches no burning so tissues adjacent to the verrucae are unaffected (causing less edema and surgical trauma) and it sterilizes as it vaporizes. Disadvantages The procedure requires a local anesthetic. Despite a dorsal injection and gentle techniques young children still do not like the idea of a needle in their foot so a routine palliative approach is preferable. The operative site must be kept very dry and covered with sterile dressings for four or five days. The procedure also involves a weight-bearing area biplane accommodative padding is used to limit pressure on the surgical site but the wound can become tender depending on the patient s activities. Obviously the more they can rest and elevate the foot the better. The Provincial Medical Plan does not cover this procedure although many insurance companies are now covering foot surgery. Ingrown Nails Although chemical matricectomy is successful when used in combination with a partial nail border removal the laser is another tool that can be used to perform this procedure. The procedure is very similar to older techniques after the offending nail border is removed the matrix is vaporized with the laser. Advantages There is less postoperative pain swelling and discomfort for the patient when the laser is used though it was already minimal with chemical matricectomy. Disadvantages Ingrown nails can recur with the laser the rate of recurrence is about 5%. An overly aggressive approach with the laser can also delay healing. Porokeratosis These nucleated deep corns respond well to treatment with the laser. While in the past they have often been excised this technique causes more postoperative pain and edema. Advantages The laser can vaporize these lesions right down to their cone-shaped apical base. There is usually no bleeding and patients are able to walk comfortably with accommodative dry sterile dressings. 9 Foot Health Advice 1999-2001 Disadvantages Patients still have to keep the operative site dry for four or five days. In the presence of biomechanical imbalance or plantar flexed metatarsal there is a greater possibility for these lesions to recur in which case the biomechanics of the foot have to be addressed. Other Uses For CO2 Lasers Onychomycosis used to be treated with the laser the nail would be removed and the mycotic nail bed vaporized with the laser. While this worked well new and effective antifungal oral medications allow treatment without any surgical procedure. Neuromas The laser works well in the treatment of neuromas. The laser cuts the nerve smoothly and microscopically rather than with a frayed edge so the risk of a stump neuroma which can lead to recurrence is lessened. Myths about lasers Lasers do not vaporize bone. Since bone does not have the water content of soft tissue lasers cannot be used to surgically treat bunions and other bone deformities. Though some podiatrists will use a laser to make the incision prior to traditional bone work they should not claim that laser is effective in the treatment of bone problems. Is it worth having a laser in your practice The laser is an excellent tool in treating some common podiatric problems one that can help both patients and practitioners. Patients appreciate leading-edge technology in the treatment of their problem so they might opt for a podiatrist- that can offer them this new approach to the treatment of common podiatric problems. Lloyd Nesbitt DPM Canadian Footcare Practice June 1999 Vol. 4 No. 1 June 1999 by Lloyd Nesbitt D.P.M. 10 Foot Health Advice 1999-2001 Plantar Fasciitis Plantar fasciitis with heel pain often referred to as Heel Spur Syndrome is due to tearing of the rigid fascia. Limiting over-pronation by orthotics can provide relief and NSAIDs and cortisone injections if necessary may be useful. Infrequently surgery is necessary. Endoscopic release of this connective tissue band followed by a stretching regime is a surgical method currently used for treatment of this problem. Heel pain is a common problem in individuals of middle and older age. It occurs in both men and women regardless of body weight occupation etc. Many individuals suffer from heel pain that is so debilitating that it interferes with daily activities. One of the most common types of heel pain is plantar fasciitis. Often referred to as heel spur syndrome this condition can be easily misdiagnosed and incorrectly treated. Clinical Picture In most cases patients describe pain in their heel(s) when first standing especially in the morning. They do not generally complain of walking or resting pain. Heel pain usually subsides after the initial 20 steps until the patient rests and then stands again. Patients also note prior over-use e.g. walking extensively while on vacation or walking 18 holes rather than using a golf-cart. A careful history and physical examination of the lower extremities is required to determine if a patient is suffering from plantar fasciitis. Radiographs that exhibit subcalcaneal spurs are of little significance since many people who suffer from plantar fasciitis do not exhibit heel spurs and vice versa. Heel spurs do not cause pain their existence and size hold very little significance. Their existence only signifies that pulling of the plantar fascia has been present for many months or years. Etiology Most of the population over-pronates (an imbalance of the foot towards the medial aspect). This mechanical imbalance causes the feet to lengthen when walking or when standing. The plantar fascia courses the entire plantar aspect of the foot inserting in the calcaneus proximally and the digits distally (Fig.l). Unlike muscles tendons and ligaments the fascia is unique in that it cannot stretch. Consequently when the foot over-pronates and lengthens the fascia pulls at its calcaneal insertion most notably at the medial calcaneal tuberosity. This constant pulling over time causes heel spurs an out pocketing of the calcaneal cortex. After the presence of longstanding stress at the calcaneus the fascia can exhibit micro trauma in the form of a partial avulsion. This micro trauma is caused by overuse and represents the acute stage of plantar fasciitis. Diagnosis If the practitioner palpates the medial calcaneal tubercle with the patient s digits and foot dorsiflexed pain is usually elicited indicating plantar fasciitis. Rarely do other pathologies such as tarsal tunnel syndrome calcaneal nerve entrapment or other enthesopathy elicit this pain on palpation of the area of the medial plantar fascia insertion. Physical examination includes gait stance analysis neuromuscular evaluation vascular examination and footwear observation. Treatment If plantar fasciitis is diagnosed and is present without evidence of systemic disease such as the sero negative spondyloarthropathies or other local abnormalities then conservative treatment should be initiated as soon as possible. Conservative management of plantar fasciitis is successful in approximately 95% of patients and surgical intervention is considered in the remaining 3-5%. Cortisone injections non-steroidal anti-inflammatory drugs (NSAIDs) acupuncture and physiotherapy provide temporary relief since they only target the resultant inflammation but do not address the fascial microtrauma. Unless the fascial avulsion is treated by reducing the pull of the fascia at the calcaneal tubercle with orthotics plantar fasciitis can become chronic and debilitating. I tend to reserve the above temporary 11 Foot Health Advice 1999-2001 treatments (i.e. injection NSAIDs etc.) until absolutely necessary. Contrary to popular belief stretching exercises are contraindicated because the fascia cannot stretch and exercise creates more trauma to the area due to overuse. Orthotics The mainstay of treatment is aimed at mechanically altering foot function using prescription orthotics to limit over-pronation this releases the stress and pulling of the plantar fascia at the calcaneal insertion. This allows the fascial avulsion to heal. Healing does not occur immediately. Most cases on average resolve within 12-16 weeks following the initiation of orthotic therapy. To provide temporary relief for patients awaiting should consist of prescription orthotics with local orthotics (about 3 weeks) we administer laser therapy about the medial calcaneal tuberosity in conjunction with orthopedic taping techniques such as a low dye configuration. Generally if physiotherapy is not proving helpful within 3-4 treatments there is little chance additional treatments will prove effective. For elderly patients a semi-flexible orthotic comprised of polypropylene or sorborthalon with EVA is prescribed. We provide a deep heel seat with poron cushion and over-correct the number of rotational degrees required. The more rigid the orthotic the less patient tolerance will be seen. The patient s shoewear weight activity level and foot architecture must be carefully considered when prescribing an orthotic device. A complete biomechanical assessment must be performed to accurately prescribe an orthotic. Computer gait analysis may determine pressure points but does not evaluate dynamic movement or rotational degree analysis. Surgery In a small percentage of patients who continue to have plantar fasciitis where conservative therapy has failed surgical intervention may be considered. In 1993 the author introduced endoscopic plantar fasciotomy (EPF) to Canada. This procedure uses an endoscope to visualize the fascia and lengthen it by severing a portion of the fascia usually the medial band. Utilizing a very tiny incision and minimal trauma EPF allows for less risk over traditional surgery and immediate patient ambulation. A 6-week plantar fascia stretching regime is mandatory postoperatively to allow the fascial separation to heal with weaker fibrous tissue. If this stretching is not followed the fascia will appose the calcaneus and heal in the original shortened position. There is a small failure-rate with traditional and EPF surgical procedures. However EPF has a superior functional outcome lower morbidity and faster ambulation recovery. Conclusion There are some myths surrounding plantar fasciitis especially the need for stretching exercises as a treatment. Furthermore at times treatments are initiated unnecessarily without an accurate diagnosis. However with a careful history and examination a proper diagnosis of plantar fasciitis can be made. Other systemic seronegative spondyloarthropathies and enthesopathies should be ruled out. Treatment should consist of prescription orthotics with local physiotherapy modalities. NSAIDs and cortisone injections should not be used initially but are reserved as an adjunct to other therapies. Surgical intervention of plantar fasciitis should only be considered when lengthy conservative therapy has proven to be less than perfect. EVA is a rubber-like compound used in almost all athletic shoes to provide the highest degree of shock absorption. Enthesopathies are a classification of seronegative spondyloarthropathies i.e. Reiter s syndrome reactive arthritis ankylosing spondylitis all can affect the heel area. MATURE MEDICINE CANADA November December 1999 December 1999 by Hartley Miltchin D.P.M 12 Foot Health Advice 1999-2001 How to Buy the Best Shoes Never have shoes been more fashionable than they are now. In part because shoes today are economically viable. In past centuries shoes were only available to the upper classes. Those who were really rich were able to slip their feet into exquisite handmade slippers. So when the industrial revolution came and mass production took over shoes were easier to gel as people just walked into stores and bought them off a rack. Now you can literally have one pair for every mood you are in. Manufacturer s try and appeal to this. Julia Pine acting curator for the Bata Shoe Museum in Toronto says that shoe manufacturers constantly introduce change in the footwear industry not because it is an artistic thing but because people are conditioned to having what is most up to date she said. Dr. Hartley Miltchin a doctor of Podiatric Medicine agrees. When it comes to fashion most women will put aside comfort for vanity he said. They would rather suffer the discomfort and look good rather than feel comfortable. The downside is it can cause all kinds of problems. But buying the most expensive shoe doesn t necessarily mean you are getting the best shoe says Dr. Miltchin. The reason he says is that there are certain shoes that make more sense than others. So why buy a 400 pair of shoes when a 150 pair will do Dr. Miltchin believes that people should wear shoes appropriate for what ever activity they are doing. So if you plan on going hiking for the day then you wear a hiking boat if you want to jog then you would wear a jogging shoe and so on. There should not be one universal shoe like the cross-trainer for all sports or activities says Dr. Miltchin. In fact I find the cross-trainer isn t sufficient at all. So what should people look for before buying their shoes Certainly a good fit is at the top of the list. Light weight is also always important because the heavier the shoe the more stress you put on your lower body. Shoes should also be flexible under the ball of the foot. Finally people should be looking for shoes with good shock absorption. Men or women who wear shoes that have leather soles are basically walking on concrete says Dr. Miltchin. They are too hard which not only puts stress on the feet and knees but also on the lower back. It s best to check a pair of shoes for all of these requirements before you buy them rather than find out what you re missing when your feet are swollen. This is certainly true in the case of wearing high heels for which Dr. Miltchin says aggravates a lot of the foot s existing problems. For example a woman who has a bunion on her foot should not wear high heels especially on a day to day basis. The bunion is going to get bigger and more sore in high heels than if she stuck to wearing flats. High heels also put additional stress on the ball of the foot. They also tend to be narrower than flatter shoes. My analogy is this says Dr. Miltchin of high heels if you look at your toes as cars then you are putting five of them into a four car parking spot. 13 Foot Health Advice 1999-2001 A flatter shoe just makes more sense. For one thing says Dr. Miltchin a woman may not always want to wear a heel. However if she has been accustomed to doing so what happens is her Achilles tendon which is the strongest tendon in the human body will shorten and become accustomed to that position. If she decides to switch to a flatter shoe then the change could become very painful and aggravating for her because the tendon is now in a stretched position. If you like to wear a heel Dr. Miltchin suggests you wear one that is no higher than 1 1 2 inches. I get the shivers when a woman tells me she has to wear high heels says Dr. Miltchin. I always ask why At work is there some sort of regulation that says you have to Another important point for people to consider is the size of their shoes. Not all shoe sizes are created equal. So if you think you are an SB that s a good place to start when asking to try on a shoe but it doesn t necessarily mean you will walk out wearing one. An 8B in a Nike running shoe may not be the same as an 8B in a Naturalizer so you have to try them on. As a podiatrist Dr. Miltchin says that 80 per cent of his patients are female. The reason lies in the shoes people are wearing. Men s shoes tend to be more roomy and fit properly. As a result they have less problems with their feet. Women on the other hand ignore their feet more. If they have a bunion they watch it grow over the years says Dr. Miltchin But if that same bump was growing on their face then they would be at their doctor s office the very same day. What he would like to see more people do is have their feet looked at on a regular basis just to make sure everything is functioning properly. Feet take a lot of abuse Dr. Miltchin says. They are very tiny bones. Like everything else if they are not treated properly eventually there s going to be some wear and tear. Amazing Feets The average person walks the equivalent of three-and-a-half times around the earth in a lifetime One quarter of all the bones in the human body are found In the feet. The average person takes 9 000 steps per day. Women are four times as likely to develop foot trouble as men. North Americans spend almost 18-bil-lion a year on footwear. The average North American buys five pairs of shoes per year. Eight pairs of ruby slippers were made for Judy I Garland when she played Dorothy in the Wizard of Oz the last pair to be auctioned sold for 165 000. The original version of the Cinderella story features a fur slipper instead of a glass one. The confusion arose in the similarity of a French word for white fur (vair) which resembled the word for glass (verre). December 2000 by Hartley Miltchin D.P.M. 14 Foot Health Advice 1999-2001 Morton s Neuroma Question With failed conservative treatment inserts injections etc. what are the pros and cons of considering surgery for Morion s neuroma and what form is recommended ALAN L. RUSSELL MD BRAMPTON ONT. Answer Most patients will tell you that they prefer to avoid foot surgery. As a physician you know that patients always run the risk of a possible post-operative infection delayed healing wound dehiscence not to mention post-operative discomfort. When it comes to neuroma surgery the pain of the neuroma is eliminated. Usually the patients are quite pleased with the overall results. The long-term however may leave the patient with some numbness in the affected toes and there is a possibility of recurrence a so-called stump neuroma. With surgery a dorsal approach can be used but for a thicker foot a plantar approach may be easier. Care should be taken so that the incision does not lie under the metatarsal head. The best way to avoid neuroma surgery is with the use of orthotic devices made from plaster casts. Patients may have told you that they have already tried orthotics and that they did not work. If this is the case they should be reevaluated for proper biomechanical control so that impingement of the intermetatarsal nerve by the metatarsal heads does not take place. In my 24 years of practice I have found that only about 5% of neuroma cases need surgical removal. LLOYD NESBITT DPM TORONTO ONT. REFERENCES Complications in Foot Surgery Prevention and Management American College of Foot Surgeons. Baltimore Williams and Wilkins Co Baltimore 114-116. Clinical Biomcchanics of the Lower Extremities Valmassey RL. St. Louis Mosbey Yearbook Inc. 1996 74-75. PATIENT CARE CANADA VOL.12. N0.12 DECEMBER 200 December 2001 by Lloyd Nesbitt D.P.M. 15