Have you ever noticed that most people in nursing homes have foot problems?
It’s not something in the water, on the admission orders, or that happens when you reach a certain chronological age. It is often the end result of life experiences while on our feet. For example, let’s say that Joe worked on feet with one leg shorter than the other.  The mal-alignment results in bones changes and the muscle imbalances , which in turn, create uneven joint wearing during motion that leads to arthritis.  Now let’s go back in time and put that same person in an appropriate orthotic which restores balance and we will likely see a different and better outcome.  In other words, a child is less likely to have the same biomechanical life experience that led to Joe’s joint wear, weakened bones and eventually pain, falls, and joint replacements.  Thus if one provides the child’s foot with an amended surface before the foot is fully formed, that child would have a less harsh interaction with his two dimensional walking surface: that is, an orthosis with a deepened heel cup for increased rear foot control and better neuro-muscular feedback.  People the world over understand the concept of adapters.  They know that an American cell phone wall charger cannot be plugged into a rural French electrical outlet because of its physical shape. An orthotic is really just an adapter from a three-dimensional foot to function on a two-dimensional flooring surface.  But let’s also consider that just as there are many other countries with differing electrical configurations, there are different foot types, ages and medical situations to consider before settling on a particular orthotic prescription. 

Just as children’s orthotics require adaptive consideration, the same is true for diabetics, runners, ion-toers, golfers, tennis players, chefs, people who are carrying extra weight, and mid-stance sportsmen who ski and skate.  Each has specific biomechanical challenges that benefit from additions and/or modifications beyond those seen in what I call boilerplate orthotics.  There are many ways to improve and further customize orthotics just as chefs use spices and sauces to improve a culinary experience.  Discuss with your Podiatrist the way you walk and any ideas he or she has for correction and remember that many in the health care field sell insoles but to have them truly be effective, there are three important considerations:
• the method used to obtain
and communicate foot structure
• the materials used
• the modifications applied to
the orthotic, both during manufacturing and after use.

The body in balance is among the most important tenets of good health.  As the concept of balanced gait begins with weight bearing, a Podiatrist will often be the first physician with the opportunity to diagnose and treat Short Limb Syndrome.  You will often hear Limb Length Discrepancy and Short Limb Syndrome used interchangeably but the former is a unidimensional statement of anatomical measurement whereas the later adds the issues of musculoskeletal effects and biomechanical compensations.  It’s a kin to looking at The Mona Lisa and noticing only the face.  Without the full picture, nuance, background and context, you may be able to make a diagnosis but you will be unable to create a comprehensive treatment plan that considers the the whole body.  Microtauma caused by postural and functional asymmetry contributes to spinal facet, hip and knee wear and degenerative joint disease.  By addressing limb length discrepancy as well as compensatory foot position and function you may save a patient from future joint problems and replacements. 

To begin to piece together this puzzle of pathology we begin, as always with a good history and physical, including gait analysis.  Often we recount a familial history or a specific incident which caused musculoskeletal imbalance.  Issues such as accidents and disorders like scoliosis may clue you in to unequal limb length.  In other cases, it’s as easy as remembering that one pant leg gets shortened more when visiting a tailor. 

On visual inspection, look for unilateral abnormalities like bunions, bone spurs, keratoses and arch drop.  Additional evidence may come from checking for head tilt, shoulder/breast/hip drop, patellar position, spinal curvature and increased foot abduction often seen on the long side.  Physical examination may reveal a relatively tight or short Achillies Tendon, most often on the short side, palpable bone spurs and/or bony hypertrophy proximal to the medial longitudinal arch on the medial dorsal surface and imbalances in strength and laxity in tendon groups.  And then there is the issue of actual measurement.  There are many different methods that range from radiographic to tape measures.  However you choose to evaluate limb length, consider that this is an anatomical measurement in a static position.

A leg rotated in the direction of the mid line of the body will functionally lengthen the limb when walking, while “duck foot” on one side, cause the affected limb to behave as if it were short.  Bearing in mind that the body goes through compensatory changes when a person has been living with long term Short Limb Syndrome, adding a heel lift does not undo these musculoskeltal accommodations and can through the whole body into a tizzy.

The rule of thumb is to start slow.  First, are there any problems or has the body fully compensated for the imbalance.  If there are concerns, the suggestion is to begin by raising the short limb 1/2 the limb length discrepancy with a graded sole lift and see how the body handles the change.  A heel lift may be appropriate initially in situations where the Achilles Tendon is short or tight.

As Podiatrist function as Dermatologists, Physical Therapists, Neurologists, Surgeons, Biomechanists (and so on), of the foot, choose your Podiatrist based on your foot concerns and your health care bias.  For instance, maybe you’re a person who wishes a more holistic approach, ask your local Podiatry offices if they focus on any particular set of foot problems or sub-specialties within the Podiatric sphere of knowledge.  Take for instance a patient with a bunion.  Podiatrist A may approach that bunion surgically, Podiatrist B might suggest an examination of the way you walk to determine the etiology of the bunion and seek to correct the gait problems with a device to alter the walking and standing pressures. 

A standard rule of thumb is to pursue and exhaust conservative therapy before considering a surgical intervention.  This may not be the case with urgent and worsening situations such as infected ingrown nails.  Experience shows maladies like that infected ingrown nail tend not to get better with antibiotics alone.  The offending nail margin needs to be removed and then healing can begin.
When folks call my office, we tell them the we handle all foot concerns, to include nail problems, fungus, heel pain, warts, and emergencies such as infections, foreign body removal, broken bones, sprains and other forms of trauma.  We add that our office specializes in walking disorders, computerized gait analysis, orthotics, biomechanics, holistic and conservative therapeutic foot care, then guide them to our website for more information. 

www.SegelPodiatry.com

I remember waking up one morning and swinging my legs out from under the sheets and placing my feet on the carpeted floor.  Wiping the sleep away, I leaned forward, head down, and there they were.  Feet that looked more like my father’s than mine.  Feet, with changes in color and shape with a new kind of stiffness I hadn’t felt before.  Some changes to our feet come from traumatic events but the majority of foot problems come from imbalances, repetitive harmful motions which cause microtrauma, and our foot type—predispositions we may get from our parents.  In other words, we are the inheritors of our parents feet.  Having said that, I should add that with thought towards prevention and early intervention, we can improve our muscular imbalances, cut down on microtrauma and mitigate our otherwise predestined foot problems.  The old “ounce of prevention” adage, being worth a “pound of cure”  certainly applies to foot care because once a foot problem gets bad enough or reaches a certain threshhold, we begin to alter the way we walk, whether we know it or not.  Exercise, proper foot wear and hygiene will go along way to promote long term foot health.  Also, a well visit to the Podiatrist could uncover emerging issues undetected by a lay person but evident to the skilled professional.

The Podiatrist is a Doctor Of Podiatric Medicine, a degree which takes four years of Specialty Medical School after completing undergraduate studies.  The Podiatrist course load includes Anatomy, Physiology, Pathology, Microbiology and Emergency Medicine like other medical schools but have specialty classes such as Podiatric Surgery, Biomechanics and Podopediatrics.  Rather than concentrating on a specific body system like a Neurologist or Dermatologist, the Podiatrist is an expert on all body systems in their region which focuses on the foot and includes the ankle in some states.  So, if it’s a problem with the foot, whether it’s a rash, broken bone, plantar warts, pain, nail concerns or trouble walking, don’t get cold feet, consider visiting the Podiatrist for answers.