The Mysterious Foot Orthotic

Orthotics Sales Approach $5 Billion Per Year

The term “Foot Orthotic” refers to everything from the inexpensive drugstore pre-fabricated insoles to costly, custom-made devices specifically molded to the foot. Podiatrists generally consider orthotics to be custom-made devices, specifically made from a mold of the patient. Podiatrists spend a great deal of time and energy understanding the biomechanics of the foot and when designing an orthotic for patients, consider the patient’s biomechanics and other factors. The CMAJ article quoted a study by Global Industry Analysts showing that the orthotics market is booming and could reach total sales of nearly five billion dollars in the next few years.

I Discussed the Problem of Possible Muscle Atrophy

The CMAJ article quoted me in saying that “You can’t guarantee anything is going to work for everyone, because people are so variable. Orthotics can do amazing things for many people, but not for everyone.” I stated that “there isn’t even a consensus on what an orthotic is,” and discussed the risk of foot muscle atrophy when relying on orthotic devices. “When you brace the foot, that may alter the function of the foot for the better, but in doing so it negates the need for many of the muscles in the foot to do anything. Common sense tells us that if you don’t use a muscle, it’s going to weaken.“

The Mechanics Of Orthotics Are Still Largely Unknown

Benno Nigg, professor of biomechanics and codirector of the Human Performance Laboratory at the University of Calgary, Alberta stated that there is no conclusive evidence of the actual mechanism of function of orthotic devices. “Orthotics can work and can have fantastic effects, but we don’t know how they work,” adding that “we don’t really understand what we do.” Nigg discussed the hypothesis that orthotics help shift improper skeletal alignment. “Maybe we should not think of pushing the skeleton around, but rather about finding ways to give signals to the body to do the right thing,” Nigg said.

Dr. Nigg has just published a new book, Biomechanics of Sports Shoes, and I’ll be posting a review of that work in an upcoming blog.

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Your Pedicurist Could Be Your Foot's Best Friend

Pedicurists have had a bad rap lately. They have been accused of not sterilizing their instruments properly, leading to infections in their clients’ feet. When I heard about these pedicure-related infections, I contacted a local pedicure school. I quickly found—to my relief—that sterilizing instruments was not a problem. However, in talking with the teachers and students I realized that these professionals were on the front lines of looking at feet and were the ideal people to spot foot problems or cancer in the foot early.

Now, I lecture regularly to pedicurists on common foot problems to watch for, including certain kinds of cancer that may show up in the foot first.

For some people, their pedicurist looks at their feet more than anyone else–including themselves. In fact, some people have difficulty seeing between their toes or under their feet and the person best suited to check all these areas, is their pedicurist.

Checking your feet regularly for any suspicious moles, masses or other lesions is very important. A mole may be nothing to worry about or could be melanoma, a type of cancer.

Melanoma starts as a small mole, lesion, or freckle. When melanoma occurs on the foot it is usually not caught until it is too late, often resulting in the loss of the foot or leg, and even death. Each year more than 8,000 people die from melanoma—nearly one death every hour.

Fortunately, when caught early, most people with melanoma survive. Melanoma does not discriminate. It occurs in the young and old, in African-Americans and in Caucasians, and in males and females. Though, Caucasians or fairer-skinned people are at higher risk.

Always have any suspicious lesions, masses, pain, or swelling, thoroughly checked by a good podiatrist.   

Diabetics should watch their feet for any pain, sores, infections, abnormal sensation, or color changes. The smallest sore, blister, or infection can quickly accelerate to a severe problem or gangrene, and quickly lead to the need for amputation of a toe, the foot, or even the leg. Studies show that one in five diabetics will endure an amputation. Sadly, most of these amputations are preventable, if caught early. As a general rule, diabetics should have any foot or ankle problem checked by a podiatrist.

Recently, I was interviewed about my efforts to enlist pedicurists in spotting serious foot problems early. Read the whole story by CLICKING HERE.

Lastly, the next time you choose a pedicurist, you may want to find someone who a basic knowledge of foot problems. It could just save your life.

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I know most people think their feet get enough exercise, but walking—even a lot—in supportive shoes, does NOT exercise your feet. It may exercise your legs and your triceps, but not the 18 muscles in each arch of our feet or  many of the other muscles entering our feet.

Supportive shoes, arch supports, and orthotics allow our feet to function without needing to work most of our foot muscles. As the saying goes, use it or lose it. Worse, without strong muscles our feet are at risk for injury.

In general, shoes are detrimental to feet. Scientists and doctors have known about the effects of footwear on our feet for over 50 years, but most of the public believes feet require expensive, supportive shoes. In fact, in 1949 The Journal of the National Association of Chiropodists published “Survey of Feet in China and India That Have Never Worn Shoes.” The researchers concluded:

“People who have never worn shoes acquire very few foot defects, most of which are painless and non-debilitating. Shoes are not necessary for healthy feet and are the cause of most foot troubles. Footgear is the greatest enemy of the human foot.”

Clearly, the first step to healthy feet is to give up supportive shoes—or at least limit the amount of time your feet are in shoes.

By simply walking barefoot, you will start to use your foot muscles and your feet will soon become stronger. (Note: Only healthy people should give up their shoes. Persons with diabetes, poor circulation, impaired sensation or other serious problems should wear shoes.)

The best way to wean off supportive shoes and increase barefoot activity is by going slowly, and by supplementing barefoot activity with foot exercises.

Now, there are two sources for foot exercises. One is the book Fantastic Feet by Aliesa George and the other is the FootBook by Dr. Paul Conneely.

Fantastic Feet and the FootBook are both great little books with plenty of photographs and detailed, easy to understand instructions. Fantastic Feet is for the public, written in layperson’s terms. The FootBook is for physicians, written in medical terms. Some of the exercises in the books are the same but many are different, and for those who are serious about their foot health, both books offer unique and highly beneficial exercises.   

These books provide a superb workout for your feet, ankles, toes and arches. In fact, many of the exercises will benefit your entire lower extremity! From each book you can choose a handful of exercises that suits your needs and soon you will be on your way to healthy, strong feet.

References:

FootBook

Fantastic Feet

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What is the best shoe for children?

Myths and false information abound about children’s shoes, and the footwear industry and even some pediatricians are not much help. The good news is once you understand what makes children’s feet unique, finding the right shoes—often inexpensively—for kids is easy.

At birth, the newborn’s foot is soft and flexible, and is loaded with fat. That fat cushions and protects our feet, but when we start to walk, the fat begins to disintegrate. In the coming decades, due to everyday walking—not to mention, perhaps tight fitting shoes—that fat will wear away allowing our foot bones and their rough edges to dig into our skin, often causing corns, callouses, blisters and other painful conditions. Ironically, feet are the only body part that loses fat as we age, yet it’s the one place we need it. I’ve often mused that perhaps some day we’ll go for a tummy tuck and walk out with plump, happy feet.

Besides fat, a newborn’s bones, muscles and ligaments, are incredibly soft and pliable. This is good and bad. It’s good because a baby that is born with a deformed foot often doesn’t need surgery. A brace or a cast can “push” the foot into its correct position. The downside of such a flexible foot is that if parents choose the wrong shoes or footwear for their children, they could create a deformity for their child.

Don’t be in a hurry to buy shoes for your child; wait until your children begin to walk, usually at 11 to 15 months of age. Even then, the MOST IMPORTANT THING TO DO IS KEEP SHOES OFF YOUR CHILD’S FEET AS MUCH AS POSSIBLE.

I cannot emphasize this enough! The best “shoes” for your children is no shoes!

Allowing kids to walk barefoot on various surfaces, especially mildly uneven ones like you find in most backyards, fosters development of their foot’s muscles, ligaments, and balance.

Shoes Can Harm Your Child’s Feet

To see the effect shoes have on feet, scientists compared American feet to those of African natives who had never worn shoes. Most natives’ had a straight big toe, whereas the Americans’ big toe tilted toward the second toe, often causing a bunion—a bump on the inside of the foot. This deformed big toe is due, in part, to shoes curving inward at the toes, presumably to give feet a slender, pointed appearance.

Am I saying shoes are bad for your child’s feet? Yes! However, we need them though to prevent injuries and for warmth. The key is to make sure children only wear them when absolutely necessary.

Socks can also be a deforming force as well, limiting a baby or toddler’s ability to spread and wiggle their toes, and develop their toe muscles. Young children should only wear socks when in shoes. If you need to keep your child’s feet warm, use soft, loose fitting booties.

When shopping for shoes, choose a shoe with ample room for the child’s toes to move. I recommend a finger’s width of space at the tips of the toes, and to help your child avoid developing bunions, the shoe should have as little curvature as possible at the big toe. Look for shoes made of natural, breathable fabrics such as leather or canvas that are soft and pliable—just like your child’s feet. You want the foot protected but it should also “feel” the ground.

The traditional baby shoe with its stiff upper and hard sole is the worst thing for young feet. 

Parents notice when their child outgrows a shirt, but not always when their shoes are too small. Children’s feet grow at different rates so the time to buy new shoes varies greatly. I’ve seen kids grow an entire shoe size in a month. If your child starts pulling off their shoes, it could mean they’ve outgrown them.

Lastly, consider shopping at a shoe store that specializes in children’s feet and has the expertise to ensure a proper fit.

Final Thoughts on Children’s Shoes

Shoes are not healthy for your child’s foot. However, they are necessary. The key is to make sure you buy a barefoot-friendly shoe and keep it off your child’s feet as much as possible.

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Is it time to take off your shoes?

Few people would deny that exercise is good for us, and our feet. Now, mounting evidence suggests that exercising the foot’s arch muscles can not only strengthen our feet, but may even increase the height of our foot’s arch.

Our feet are one of the most muscle-rich areas of our body. In fact, there are 18 muscles within the arch of our feet, with additional muscles originating in our leg, inserting into the arches.

It is well known that the more a muscle is worked, the stronger it becomes. Of course, the converse is also true (we have all heard “use it or lose it”).

Now, breakthrough research by Headlee and Fiolkowski shows that when the muscles within the arches of our feet weaken, the arches will actually lower and become flatter.

If the foot’s arch decreases when our foot muscles weaken, it reasons that strengthening the muscles in our foot will raise the arch. Anecdotal evidence from runners who run barefoot shows this to be the case. These barefoot runners relate stronger arches and higher arches. Research by Robbins supports these findings.

Robbins showed radiographic changes in the feet of runners who gave up their shoes and began to run barefoot. In his study, the bones that make up the ball of the foot were shown—radiographically—to move closer toward the rear of the foot. That is, barefoot activity shortened the length of the foot’s arch. Robbins paper did not say the arch increased in these barefoot runners, but when the foot’s arch shortens, it height must rise.

Recently, Mark’s Daily Apple commented on the beneficial effects of exercise on feet, and I second it. Shoes lessen the need for and use of most of our foot’s muscles. As a result, the muscles weaken and the arch will weaken.

It’s time to take off your shoes and start exercising your feet.

I have written previously about foot exercises HERE.

The best foot exercise is barefoot activity — walking, running and playing barefoot! Barefoot activity is the best way to strengthen the muscles of your feet (assuming that you have good health — that is, you are not diabetic or plagued with poor circulation or other ailments). 

Like any exercise, start slow. Let your foot muscles gradually adapt to barefoot activity, and only go barefoot in safe environments – there’s no point having good foot muscles if there is a nail in your foot!

References:

Fiolkowski P, Brunt D, Bishop M, Woo R, Horodyski M. Intrinsic pedal musculature support of the medial longitudinal arch: an electromyography study. J Foot Ankle Surg. 2003 Nov-Dec;42(6):327-33.

Headlee DL, Leonard JL, Hart JM, Ingersoll CD, Hertel J. Fatigue of the plantar intrinsic foot muscles increases navicular drop. J Electromyogr Kinesiol. 2008 Jun;18(3):420-5. Epub 2007 Jan 8.

Robbins SE, Hanna AM. Running-related injury prevention through barefoot adaptations.Med Sci Sports Exerc. 1987 Apr;19(2):148-56.

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Treating Corns Wrong Could Lead to Serious Problems

Deidre writes:  I tried to get rid of two corns, one on each of my second toes. First, by using a drugstore corn remover medication and then with a tca peel. Now both my toes are extremely darker than all the other toes (my toes look burnt) and the corns are still there. I now wear better shoes and i scrub it everyday, but nothing.

Dr. Nirenberg replies:

A corn on our toe or between our toes can be very painful, and can interfere with our ability to walk normally. However, corn remover products are not always the best solution and may, in fact, prove harmful.

When a corns forms on our toe it is usually the result of an abnormality or misalignment of the bones inside the toe. The bone under the area of the corn may be abnormal and may have a spur or some other kind of growth, or the toe itself may be bending (contracting) and you may have a mallet toe or hammertoe deformity. A deformity of the toe or misalignment of the bones causes pressure on the skin from within and rather than the skin breaking open, it toughens and forms the corn (to protect it). A hammertoe (or mallet toe) is the number one cause of corns on the toes. Often patients may have several hammertoes, but not all of them will have a corn.

Corns can also form in response to pressure from outside our foot, such as when a tight-fitting shoe rubs on the toe. Again, the skin will toughen and the corn will protect the skin from the opening.

Many drugstore remedies for corns use a medicated solution to soften and remove the corn. These “medications” are usually an acid that burns away the corn. Putting acid on a corn (or burning the corn) will make the corn look burnt, as you describe. The problem is, if you use too much acid it can burn through the skin. In my podiatry practice, I have even seen patients put on so much acid that it burned to bone and/or caused infection or gangrene. Some patients have needed the toe amputated. Essentially, the acid does not stop after destroying the corn and goes through the good tissue, resulting in gangrene or infection in the toe or worse, the bone.

The other problem with using these remedies is that the patient is not addressing the corn’s cause: the bone. At best, the acid is briefly alleviating the corn. Without addressing the bone beneath the corn, the corn is likely to return. For all these reasons, I advise patients never to use drugstore medications for corns.

Whether your corns are due to hammertoes, mallet toes, spurs or other bone problems, you do not have to live with them.

The best treatment for corns is to pad them with moleskin, wear loose fitting shoes and have a good podiatrist examine your foot. The podiatrist will take an x-ray and you will immediately see how the bone is causing the painful corn or corns. From there, the doctor will explain the treatment options for the corn.

Additional Information:

Wikipedia

Mayo Clinic

Photos

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Metatarsus Adductus

Jon writes: 

Ok I’m 18 and I have metatarsus adductus. I was treated for it when I was younger but I did not do anything. It does not really affect my athletic ability too much. Sometimes I feel like I’m off balance. Other then that, I was just wondering if there’s a cure for it since it’s noticeable.

Dr. Nirenberg replies:

Metatarsus adductus (met adductus) is a deformity where the forefoot turns inward, and you are born with this deformity. It is not common. A podiatrist should be able to spot this problem fairly easily.

The best time to treat metatarsus adductus is early – when the child is an infant. At birth our bones are pliable and the podiatrist will treat this deformity by placing the child’s foot in a cast that gently nudges the foot back into its correct position.

If an adult has pain or problems associated with metatarsus adductus (med adductus), most podiatrists would recommend trying a special arch support called an orthotic. Orthotics help balance the foot by placing it in a more normal position.

If an orthotic does not work, then one would need surgery to “fix” the problem. The good news is that most adults with metatarsus adductus do not have a lot of problems and surgery is rarely necessary.

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I have gone barefoot nearly my entire life. When I wear shoes, sandals or boots, my feet get so hot, sweaty and then start to swell until I am barefoot again. Often even sandals will make them sweat and swell. Other than get a doctors note to go barefoot, what else can I do?

Dr. Nirenberg replies:

I love that you have gone barefoot nearly your entire life! That is great, and generally, going barefoot is very healthy for our feet. Unfortunately, at some point, we are forced to wear shoes and for the sweat glands on our feet this is a problem.

Our feet are not meant to be confined to shoes–the more you are barefoot, typically the better.

When a foot is entombed in dark, secure shoe, the sweat of our feet has nowhere to go—it can’t evaporate. Often, bacteria can fester, leading to foot odor and infections. (Sweat in itself does not have a odor but the bacteria cause the odor).

In areas of the world where people do not wear shoes, sweaty feet and for that matter, foot odor, is rarely a problem.

Our feet our loaded with sweat glands. In fact, our feet have a higher concentration of sweat glands than any other part of our body. Some people’s feet can secrete up to half a pint of perspiration a day! The medical term for over-active sweat glands is hyperhidrosis.

Excessively sweaty feet (hyperhidrosis) can cause athlete’s foot, blisters, foot odor, infections, and can be just plain irritating.  

What Causes Our Feet to Sweat Too Much?

Excessively sweaty feet may be due to hormonal imbalance, thyroid problems, or your genetics. Hot weather can worsen sweaty, wet feet, though I have seen the problem occur in the winter too.

As mentioned above, shoes are a big part of the problem. Make sure your shoes are breathable as possible. In general, avoid shoes with synthetic materials such as vinyl, plastic or nylon. Wear leather shoes if possible.

How Can I Treat My Sweaty Feet?

1.Sprinkle a good foot powder, one with zinc, in your socks.

2.Use a good spray anti-perspirant on your feet, such as Gold Bond Foot Spray

3. Wash your feet daily. This doesn’t mean standing in the shower and letting the water hit your tootsies! Use antibacterial hand soap and wash your entire foot, including between the toes. Then dry your foot completely (and dry between the toes).

4. Wear good socks that wick moisture away from your feet, and change the socks twice a day.

5. Whenever possible, do not wear shoes or socks—go barefoot and let the air at your feet.

6. Wear different shoes each day–let the shoes air out, preferably in sunlight, and spray the inside of your shoes each day with Lysol. Lysol does not kill all germs, but it does kill many of them.

What Can a Podiatrist Do For Excessively Sweaty Feet?

If your sweaty feet persists, a podiatrist can prescribe topical medications to lessen the sweating.

If you have severe hyperhidrosis, some podiatrists will inject botox into your foot. Yes, you heard right! Botox can help your feet, though I doubt this is something our new, upcoming government run healthcare will pay for (or your current insurance). Botox does stop feet from sweating and it will last several months.

I hope this helps. Let me know how your feet do.

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Since I was 14, I have had plantar fasciitis. I did not know I had it until a pediatrician told me a year later.

The year before I ran in a marathon through the downtown capital of Georgia. In gym class, I ran for twenty minutes with no significant pain afterwards. A year after my diagnosis, I have walked for long distances and a long time like 10 miles and about 10 hours. All the while, I never felt any severe pain except some moderate burning and a little swelling in my foot. And I did not wear the most supportive shoes.

I have never felt pain at my heel, but above it where the arch begins and beneath the ball my foot. The burning would always subside after walking or running for long periods of time. When my foot burned or swelled I iced and rested it later. As soon as the pain went away for a while I got back to my usual exercises, walking, running, or playing sports.

I have not had physical therapy and any home remedies such as stretching, wearing orthotics, and icing I have done, but not consistently. Only until the pain subsided.

Is it too late to go to physical therapy? Is it too late for me to recover from plantar fasciitis because of all the stress I put it through?

Dr. Nirenberg’s reply:

Plantar Fasciitis

Plantar fasciitis is one of the most common problems I see, and the number one cause of heel pain. Plantar fasciitis occurs with the ligament on the bottom of our heel and foot—the plantar fascia—becomes enflamed.

The plantar fascia becomes irritated when the biomechanics of the foot malfunction and foot pronates excessively. All feet pronate, which is a complex motion that involves the heel turning outward during ambulation. Often, feet that pronate will have a low arch, but pronation can occur on occasion in persons with a normal or even high arch.

This malfunctioning foot biomechanics can cause a host of problems, including the plantar fascia to want to pull away from your heel bone or even tear (yank a handful of hair from your scalp and you will begin to understand the pain of the plantar fascia pulling away from the heel bone).

Plantar fasciitis can also cause pain in the arch of the foot. However, the fact that you relate burning, makes me suspicious that you have plantar fasciitis. I don’t want to doubt your pediatrician’s medical exam, but it sounds like you may have tarsal tunnel syndrome.

Plantar Fasciitis

Tarsal Tunnel Syndrome

Almost everyone has heard of carpal tunnel syndrome in our hands, but few people realize the same problem occurs in our feet. Tarsal tunnel syndrome may cause burning, tingling, shooting pain, or a cramping sensation in our foot, particularly in the arch and the ball of the foot. Some people will fell like the ball of the foot or arch is swollen.

The good news is that there is a light at the end of this tunnel. Tarsal tunnel syndrome is often easily treated with orthotics, injections, or a short, outpatient procedure.

Both tarsal tunnel syndrome and plantar fasciitis respond to orthotics and physical therapy, and so I would recommend these as a first step.

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Foot Articles on the Web

Here is my pick of the latest, greatest foot, ankle and podiatry related articles on the web:

Pregnancy is a bundle of joy, but not for your feet! Podiatrist Scott Kilberg has written a great review of the effects of pregnancy on our feet. Check out Foot Problems During Pregnancy and for more from Dr. Kilberg, visit his blog My Aching Foot.

Shin splints eventually affects just about every runner and Podiatrist Andrew Schneider has written a good synopsis on this common problem. His blog also has some of the best writing about our feet and ankles that you can find. Check out Dr. Schneider’s superb writing and and learn about shin splints HERE.

Bunions are among the top podiatry problems we see. Podiatrist Jennifer Feeny has written a good review – Bunions: A Pain in the Foot. Her blog can be found HERE. If you want to know when a Bunion is Not a Bunion, check out Dr. Marybeth Crane’s article HERE.

If you want to dance, you may have to pay the piper – or the podiatrist! Dance takes a toll on the feet. For a great introduction to foot pronation and how it can be the cause of your knee pain, read Lisa Howell’s How to Understand Overpronation and Knee Pain If You Have Flat Feet.  

Speaking of Flat Feet, there is a basic introduction to flat feet and Choosing the Best Running Shoes at the Running Shoe Guru.

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