Rehabilitation after injury - don't forget the other leg!

Humans are bi-pedal. When we ambulate we need two functioning limbs to move effectively.

When we walk there is a cross-over point at which both feet are on the ground together
When we run only one foot is in contact with the ground at a time. But that foot is still very dependent upon the other leg and foot providing a stable support so that landing can take place.

I have seen many cases in practice where the patient or client has been provided with foot orthotics which do not provide optimum control (which is to say, the best and most comfortable control possible for that patient at that time). Sometimes (not always) care has been taken to construct one orthotic (for the injured foot or ankle) so that it fits the foot and works reasonably well. The other orthotic is almost an afterthought.

So what I'm really saying is - don't just look at the injury - look at the whole patient. Look at the uninjured leg and foot. Choose orthotic materials based on function, not cost. Does the patient or client need bespoke footwear? If so how many pairs? Factor in age and sex. A 20 or 30 year-old female needs more than two pairs of shoes (just ask one), a 50 year-old possibly not - but possibly so - check with the patient.

Bespoke footwear and foot orthotics are just one facet of effective rehabilitation after injury, but important nevertheless. In the NHS shoes and foot orthotics are often badly made and/or badly prescribed. Cost and staffing may be used as an excuse, when really there is no excuse.

Orthopaedics may get the idea, after shoes and orthotics have been fitted and found not to work well, that only another operation will work (I've been looking at a case like that this morning).
Good bespoke footwear and correctly made and functional orthotics can perform miracles in terms of getting patients to walk comfortably again after injury.

And don't forget the other leg!

What is Podiatry?

From conversations with both legal and other (health) professionals it is very evident to me that Podiatry is something of an unknown. So here is my presentation of what UK Podiatry is, does, and the difference between UK Podiatry and Podiatry in the USA (the two are often confused).

What is Podiatry?
Podiatry is a science based healthcare profession which places emphasis on the promotion, maintenance, and restoration of foot health. A Podiatrist is autonomous, in that he or she can direct treatment without the patient being referred by their doctor.

What are the qualifications for Podiatry and how long does it take to study?
Like most other healthcare professions nowadays, Podiatry is a degree course. The degree runs for three years (four in Scotland where it can be accessed at the age of seventeen rather than the usual eighteen).
The end qualification is either a BSc(Hons) Podiatric Medicine, or more usually BSc(Hons) Podiatry. The two degree have much the same content.

Study consists of:

Year 1 - Podiatric Foundation Studies, Lower Limb Anatomy, General Anatomy and Physiology, Knowledge and Skills for Professional Practice Placement, Communication and Psychology for Health Sciences.

Year 2 - Introductory and Applied Biomechanics, Patient Assessment, Pharmacotherapeutics for Podiatrists and Pathophysiology.

Year 3 - The High Risk Foot, Medicine and Surgery for Podiatrists, Prescribing in Practice, Evidence Based Practice and Professional Issues for Allied Health Professionals. Surgical tuition in Year 3 is not confined to the foot - the first operation I witnessed as a third-year student many years ago was a hip replacement.

Although Podiatrists have prescribing rights for, and can inject local anaesthetics, and can carry out limited surgery, they are not qualified to carry out bone surgery procedures like bunion removal and toe-straightening. This requires a further period of study, both theory and practical. This is not, as one newspaper published recently (having been fed misinformation by some interested third party) a matter of a year or so. 
Bone surgery theory is covered by an MSc. Supervised practical work is then carried out within the NHS over a period of some years.

So, a Podiatrist has done some surgical training, but is not qualified to carry out bone surgery.
A Podiatric Surgeon is qualified to carry out bone surgery. He or she has done the same Podiatry undergraduate degree, but has then completed a further course of surgical training.

All Podiatrists qualifying in the USA are qualified to prescribe drugs and carry out bone surgery. 

And just to confuse matters further, some of us have done some additional bone surgery training without becoming Podiatric Surgeons........

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Case history 2.

This claimant was referred to me by a Solicitor who wanted more information and accurate costings for foot orthotics.
The Solicitor "inherited" the file, which generally means it has had a period of inactivity. This case was over four years old.

The claimant was involved  in a road traffic accident in which his left foot and ankle were injured.
Damage was such that the ankle was subsequently surgically fused, and the first and second toes were amputated.

Ankle fixation and amputation of the big toe both materially affect gait, and may also have a damaging effect upon the opposing lower limb, overloading it and the major joints within it (hip, knee, ankle and big-toe joint), and so accelerated wear-and-tear arthritis is a factor to be considered in cases where one limb only is damaged initially.

A Rehabilitation Cost Report obtained earlier for this client suggested that an annual allowance towards future specialist footwear of £400.00 would be sufficient to meet the client needs.
In my opinion this figure was unrealistically low, and probably based on NHS footwear provision costs.
I was able to provide information and references which showed that NHS footwear provision is variable, and that in this case gait, and therefore need, had not been properly assessed.
I was further able to suggest, with references, that privately-sourced orthotics and footwear could provide better comfort and functionality, and better continuity of care.

The initial costings for gait analysis, orthotics and bespoke footwear came to £3,500.00, with annual costs thereafter of £1,850.00. These costs were accepted by the other side as being reasonable.

Conclusions.
In lower limb and foot injury cases rote costings for foot orthotics and bespoke footwear may be unrealistically low.

Gait should always be assessed when lower limb damage is present.

Continuity of care is an important factor in overall rehabilitation.

Rehab case study.

Rehab doesn't always mean physiotherapy and occupational therapy.

This case study illustrates how a correctly-prescribed custom foot orthotic can mean the difference between normal walking and limping, even in a young, fit client.

An otherwise fit 28 year-old male self-referred for treatment to his left foot.
He had previously been involved in a motorbike accident in which his left heel had been degloved. Clinically, degloving presents as skin and subcutaneous tissue being removed from the hand or foot, in this case by a spinning rear spoke motorbike wheel.

The injury had been operated on successfully, and had healed uneventfully, but with almost complete loss of fatty padding from around the heelbone. This is not uncommon in degloving injuries which affect the back part of the foot. Invariably, as in this case, the client is unable to heelstrike or bear weight on the heel for any length of time. Heelstrike is an important component of normal walking, without which a subject will walk with an antalgic gait (limp). Older people who have lost flexibility in their knees and hips often demonstrate this type of gait very well.

Stock foot orthotics had been issued by the NHS. They were cushioned, but not supportive, and were ineffective in allowing the client to maintain normal gait.

Treatment.
Barefoot computer gait analysis confirmed lack of heelstrike during normal walking.
A plaster cast was taken of the left foot to accurately capture the heel-to-toe profile of the foot. A biomechanical foot orthotic was designed which featured a deep heel cup into which a substantial amount of soft cushioning was incorporated. This was to replicate and replace the natural fatty padding around the heelbone. A small heelraise was also added to the orthotic to replace limb length  lost when the cushioning compressed during weightbearing. The orthotic shell was moulded from mildy flexible polypropylene, to which robust cushioning was added from the heel to the forefoot. Specific care was taken with regard to orthotic materials given the age, weight, and likely activity level of a fit young male.

Results.
Once the foot orthotic had been fitted the client found he was able to heelstrike with no discomfort. As his bodyweight moved forwards the foot was cradled and held in a stable position to allow normal push-off to occur. After a few weeks of using the orthotic the client was reassessed. His walking was normal with the orthotic. Without the orthotic he reverted to a laboured limp.

Conclusions.
Because there is no satisfactory surgical replacement of lost fatty tissue around the heel the client will have to wear this type of orthotic for life. The successful orthotic design could also be incorporated into a bespoke shoe or boot, resulting in a low-bulk alternative. This option may be more suitable for some client groups (eg young females) for whom the ability to wear fashion footwear some of the time may be important.

The sometimes quite considerable cost of custom foot orthotics and bespoke footwear should be carefully considered in clinical negligence and personal injury cases which affect the lower limb or foot.

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Foot orthotics in the NHS. When is custom not custom?

Are our NHS patients being sold down the river when it comes to custom foot orthotics?
I think some of them are....

Foot orthotics combine comfort with theraputically-altered foot and lower limb function. They are effective in rehabilitation after injury, in sport, and for patients with degenerative disease like arthritis.

Like many UK Podiatrists in private practice I see the occasional patient who has had foot orthotics supplied by the NHS.
Invariably these have been of poor quality. Recently, over the last couple of years, I have noticed an increase in NHS foot orthotics with a label stuck underneath. The label says custom.

Not custom, or even "custom". Just a standard NHS insole. Offered along with the advice to the (female) client to buy some trainers because it wouldn't fit in her shoes! Some NHS Trusts are better than others in this regard.


Now custom foot orthotics are something I'm familiar with - and so I should be, having worked with them for over 20 years. 

Custom foot orthotics have two specific attributes:
1. They are made from an impression of the individual patients foot, rather like making a handmade shoe from an individually-carved last.
2. They are made from materials chosen to best help the individual patient. Stiffness, resilience, springiness and cushioning are all qualities which are considered at when choosing materials for custom orthotics. Carbon-fibre, medical-grade polypropylene, high and low density foams, and anti-bacterial coverings are just some of the materials used.

Custom orthotic made from medical grade polypropylene with anti-bacterial cover. To fit a ladies walking shoe (pen for scale).

I have been involved in writing two medicolegal reports recently, for claimants who both had "custom" orthotics fitted by the NHS. That they were made from an impression of the claimants feet is not in dispute.
But they were not custom, not as I understand the word.

The first report concerned a claimant who was overweight, partly due to disability stemming from a road traffic accident. The NHS custom orthotics looked like orthotics to the untrained eye, but collapsed when any weight was placed on them.
They were made from a cheap and easily-machined material called EVA. There were two pairs made. The second pair didn't fit into shoes because they were so thick - they had to be to offer any semblance of stiffness.

The other report concerned a young man who had had an accident at work. He was supplied with "custom" orthotics which certainly fitted his shoes, but didn't take into account the fact that he was young, had an excellent chance of making a full recovery, and wanted to train for his favourite sport, which was hockey.
The orthotics were made from the same floppy material as the first claimant, and had the ubiquitous "custom" sticker underneath.

What is interesting is that these claimants were not being treated by the same hospital. 
One was in Shropshire, the other Leicestershire. Information from colleagues leads me to believe that poor-quality foot orthotics are being fitted by the NHS up and down the country.

Our Gold Standard for clinical information is the Cochrane Reviews database, and I'm well aware that research which has been included in Cochrane has shown that there is not much difference in action between custom and inexpensive over-the counter foot orthotics. This finding would allow any cash-strapped NHS Trust to offer cheap sub-standard foot orthotics to their patients without comeback. If the manufacturers of such orthotics were to stick a little custom label on the bottom of their orthotics they could probably charge the Trust a little more.
My own view is that although the Cochrane database is an undoubted valuable source of information, in this case it is wrong. There are many reasons why research can be biased, and I believe bias is rife in this particular area.

For more information on another example of how Cochrane may not be 100% correct 100% of the time you could go here British Medical Journal (clicky)


For those lawyers contemplating costings for their clients which may involve custom foot orthotics it is important to note that if there is a need the client will already have been provided with NHS foot orthotics.
This establishes the need, which then cannot be disputed.

In most cases the Bolam principle will not apply, because the need has been established and neither the need nor the treatment principle is in question. The efficacy of the orthotics is though, and it can easily be demonstrated that the efficacy of the NHS orthotics is poor.

True custom orthotics, bearing in mind the claimant will need several pairs, and these will need replaced over a lifetime, are not inexpensive.


For more information or to contact me go here

Barefoot and minimalist-shoe running. Good or bad?

This debate has been going on for a while. It led, indirectly, to legal action against running-shoe companies Vibram and Adidas.

Advocates of barefoot running and minimalist-shoe running maintain that running without normal running shoes is better, and makes you less prone to injury.
Here is the thrust of their argument.

As a Podiatrist I have no problems with occasional barefoot running, or minimalist-shoe running.
I do have a problem with the "barefoot running is better for all" approach though.

Here's why:
Our feet were designed to work barefoot, agreed. But barefoot on a multitude of surfaces.
Homo sapiens is nothing if not adaptable. Our feet work well on a mixture of hard, flat, undulating, soft - even up a tree if that's where you have to go for food.
In the West, where most of us walk around on hard, flat surfaces for over 90% of the time, we find it more comfortable to wear shoes or sandals, at least for some of the time - because we were not designed solely for hard and flat surfaces.

Shoes and sandals cushion and create a comfortable interface between the ground and our feet. Having that little half-inch heel doesn't hurt either.

Creationist or evolutionist?
Whether you hold that we were created in God's image in the Garden of Eden some eleven thousand years ago, or that we have evolved from ancestors living millions of years ago doesn't make much difference as far as establishing what our feet were designed for.
As far as we know there was no concrete in the Garden of Eden. It's a certainty that there was no concrete two million years ago - maybe the odd flat rock.

Have a look at the skeleton here. He's way over eleven thousand years old, and his leg bones (and probably foot bones) are much the same as yours or mine. He's designed for adaptation, and fast and adaptable ambulation over a variety of surfaces.
He's probably not designed to live for more than forty or fifty years. Back then slowing down meant starve or be eaten. Joint wear-and-tear did not happen to the extent that joints ceased to function, as happens now. The entity ceased to function long before individual joints.

Our legs and feet have not miraculously evolved in the time we've been living on hard, flat surfaces.
Genetic changes of that magnitude take much longer than a couple of hundred years to happen.
The reality is that we still possess lower limbs which have been designed for adaptation, and fast and adaptable ambulation over a variety of surfaces.

 Barefoot running for any length of time on a hard, flat surface is not natural, and therefore somehow good for you. Some barefoot running on an appropriate surface like sand may be good for you. Running barefoot all the time is a fad, and likely to cause injury in the long-term.

Minimalist or barefoot running shoes were born from the need for some barefoot runners to wear some protective footgear.
Predictably, as they developed so did the advertising hype - based, it would seem, on less than robust research results......

SportsOneSource are reporting:
Vibrams FiveFingers Sued over Health Claims 

Quote:

A group of five law firms has filed a class-action suit against Vibram USA Inc and Vibram FiveFingers LLC in the U.S. District Court for the District of Massachusetts alleging the company used deceptive statements about the health benefits of barefoot running.

Quote:

The lawsuit asserts that; 1) health benefits claims Vibram FiveFingers has used to promote the shoes are deceptive; 2) that FiveFingers may increase injury risk as compared to running in conventional running shoes, and even when compared to running barefoot; 3) that there are no well-designed scientific studies that support FiveFingers claims.

More information about the similar action against Adidas here..........