High Heels and …..Orthotics?

What better way to end the year than to talk about something that some of you have worn last evening. Not only clean underwear, but also high heels!

You have heard all about high heels here on the blog (if not, click here). Now here is some info that may be surprising! This study found that increased heel height caused increased plantar pressures (no surprises) BUT the use of an orthotic or arch pad, attenuated impact forces. IOHO not a reason to wear heels (though we DO like the way they look : )) but if you need to wear them (really? you need to wear them?), then maybe consider an insert to make it more bearable.

Ivo and Shawn                                              

                           

Appl Ergon. 2005 May;36(3):355-62.

Effects of shoe inserts and heel height on foot pressure, impact force, and perceived comfort during walking.

Source

Department of Industrial Management, National Taiwan University of Science and Technology, No. 43, Kee-Lung Road, Sec IV, Taipei, Taiwan, 106 ROC. yhlee@im.ntust.edu.tw

Abstract

Studying the impact of high-heeled shoes on kinetic changes and perceived discomfort provides a basis to advance the design and minimize the adverse effects on the human musculoskeletal system. Previous studies demonstrated the effects of inserts on kinetics and perceived comfort in flat or running shoes. No study attempted to investigate the effectiveness of inserts in high heel shoes. The purpose of this study was to determine whether increasing heel height and the use of shoe inserts change foot pressure distribution, impact force, and perceived comfort during walking. Ten healthy females volunteered for the study. The heel heights were 1.0cm (flat), 5.1cm (low), and 7.6cm (high). The heel height effects were examined across five shoe-insert conditions of shoe only; heel cup, arch support, metatarsal pad, and total contact insert (TCI). The results indicated that increasing heel height increases impact force (p<0.01), medial forefoot pressure (p<0.01), and perceived discomfort (p<0.01) during walking. A heel cup insert for high-heeled shoes effectively reduced the heel pressure and impact force (p<0.01), an arch support insert reduced the medial forefoot pressure, and both improved footwear comfort (p<0.01). In particular, a TCI reduced heel pressure by 25% and medial forefoot pressure by 24%, attenuate the impact force by 33.2%, and offered higher perceived comfort when compared to the non-insert condition.

Podcast #17: Gait and Magic (and much more !)

Podcast Link:

http://thegaitguys.libsyn.com/podcast-17-magic-gait

iTunes link:

https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

__________________________________________________________

Gait, Magic, Evolution, Foot Types, Stretching, Cases studies…… we have it all on today’s podcast.

Show Links
“How does the brain work ?”
 Nova Science Now
www.video.pbs.org   

buy this NOVA program now ! Educate the world ! :
http://www.shoppbs.org/product/index.jsp?productId=11095035&utm_source=PBS&utm_medium=Link&utm_content=nosn_nova6215_howbrainworks_covebuyit&utm_campaign=cove_buyit

Other links for today’s show:

http://www.medlink.com/medlinkcontent.asp

http://www.ncbi.nlm.nih.gov/pubmed/12763089

http://www.ajronline.org/content/184/3/953.full

1. Hi Guys,
I was wondering if you could direct me to a podcast/video or elaborate on how a fast stretch can relax a hypertonic muscle in a practical setting. Can manual stretching techniques like MET be use by altering the technique with a short fast stretch or are you just referring to high velocity low amplitude manipulation? We are often taught to find the barrier apply contraction and then ‘gently’ go to the next barrier. Is this still a good way of activating the GTO’s?Also do you have any further discussion I can check out on GTO’s?

Thanks for your time, Adrian

2. Hello, GAIT Guys!

First I want to thank you for your phenomenal work!
I work alot with athletes and there are so many that have some sort of sole into their shoes. Problem was, pretty much everyone, didn’t get the answer to WHY they needed them. Just the normal “your foot pronates” and frankly, 1 out of 40 got better.
I was driven by the question WHY, searched around in Sweden, attending lectures, orthophaedic clinics etc, but I didn’t get the answers that I was looking for.
Started to look into it deeper for myself, when I found you guys!
Now I want to bring back that knowledge to Sweden, cause frankly.. WE NEED IT!
Can you tell me more about your certification? Is it possible for a Swe to attend and get the certification?
Best Regards
Gabriel
Dr. of Naprapathy from Sweden

3. Hello Drs. Waerlop and Allen. I need some clarification on gait biomechanics. Will using a more “minimalist” running shoe or a shoe with less RF to FF delta help peroneous longus to gain mechanical advantage? If someone has a forefoot varus would recommending a lower ramp shoe be appropriate to help “retrain” the tripod at stance phase? 
John F

4. Another blog question…ivo said in podcast #15 that most people have a forefoot abnormality (during section talking about flares). Any idea Why? Is it skewed toward one way or the other?
After looking at quite a few feet since becoming shoe fit certified, I’ve noticed quite a lot of variation. If I was pressed if say I’ve seem <10% FF valgus and maybe half of the rest each neutral and varus. Is that in the ballpark of what you guys see?
How about rear foot? I feel like I see a lot of rear foot varus but maybe my frame of reference is not accurate? If I was pressed, I’d say 70% varus, 29% neutral, 1% valgus. Does that seem off?
Thanks, Eric J

Category
Educational

Here Dr. Allen of The Gait Guys introduces some of the initial information necessary to understand proper shoe fit. Topics include body anatomy, shoe anatomy, physiology, biomechanics and compensation patterns. This was part of a private industry lecture where The Gait Guys were asked to help improve the understanding of the concepts critical to better shoe industry choices.

The pedograph as a window to the gait cycle

Have you ever studied footprints on the beach or looked at the print left by a wet foot when you get out of the water? These are some of the most primitive types of pedographs.

The pedograph, 1st described by Harris and Beath in 1947 is a rubber mat surface with multiple protruding, small grid lines on one side, which, when covered with ink, imprints an underlying sheet of paper when weight (usually a foot) passes over it. Relative plantar pressures are indicated by the size and density of the inked area, creating a “footprint” reflecting passages of force through the foot at that instance in time.  They have fallen into and out of usage over the years, often discarded for more expensive technology such as pedobarographs, individual pressure sensors, and pressure sensitive mats, which have computer interfaces and can provide many useful measurements and calculations to assist the clinician with rendering a diagnosis. These systems, though more precise in some ways (provided a controlled, reproducible testing procedure) are often thousands of dollars, require a computer and the necessary skills, and have a substantial learning curve. 

The pedograph in contrast is simplistic, inexpensive, and reliable and only requires that the user have an intact visual pathway and cerebral cortex and knowledge of the events occurring in the gait cycle. With some practice and a good knowledge base, the subtle nuances detected by the sensitive pedograph (nuances that can be undetected with high end computer driven plantar pressure devices) can offer information critical to a precise diagnosis and give solid clues to gait flaws and compensations.  With minimal training using a pedograph, reproducible “prints” can be produced for analysis, in light of your findings clinically. They also make wonderful educational tools for your patients and clients!

An essential part of a comprehensive patient evaluation should include examination of the entire kinetic chain both in a static and dynamic fashion. Often what you see statically is either directly translated to or compensated for in the dynamic evaluation. (It is important to note that many of the available foot scan units available from orthotic companies scan a patient in a static standing position and give little information on how the feet and lower limb dynamically engage the ground during movement.) The pedograph is a useful visual tool representing a 2 dimensional image of tridimensional motion, and you are seeing the end product and compensation (or lack thereof) of the individuals mechanics at that point in time. Because of the specificity of what you are seeing refers to a particular point in time, technique and reproducibility are of paramount importance. Prints should be performed several times to insure what you are looking at is what you are looking at, and not movement artifact, because of the way the patient stepped on to or off of the mat.

With a pedograph, seeing is believing. When you have objective data about how an individual moves through space and how their joints and motor system help them to accomplish that, you have a better appreciation for the type or form of therapy which may be most appropriate. In the hands of a skilled clinician, seeing abnormal plantar pressures tells you where the biomechanical fault lies, and thus where manipulation may be appropriate, which muscles need strengthening and where neuromotor coordination is lacking and gait rehabilitation is needed.  

excerpted from the 1st edition of our Book “Pedographs and Gait Analysis: Clinical Pearls and Case Studies” Trafford Publishing

How do I know if my orthotic is working?

Foot orthotics are easy, no? You get casted, it gets built, you put it in your shoe and you’re good to go, right? Wrong!

Orthotics or “Orthotic Therapy” as we call it is an ongoing process. If an orthotic is doing it’s job, your foot should change (for the better) and your prescription should become less. and less….Until you no longer need them… At least in an ideal world.

Remember, orthotics are designed to help you adapt to your environment better. Unlike a footbed, they should change the biomechanical function of your foot. A lot should go into getting fit for an orthotic, otherwise they can actually cause some of the problems they are purported to fix!

First of all, there should be a history of you and whatever is going on, with an inventory of all your past injuries. Sometimes there is a pattern that can be recognized and gives your provider clues as to what may be going on with you.

Next you should have a thorough examination of your lower kinetic chain, including the feet, ankles, knees, hips and low back. This should include range of motion, muscle strength, muscle recruitment patterns and joint function, along with reflexes, sensation and balance or proprioception. This gives us a benchmark and defines weaknesses and strengths.

Now there should be an analysis of your gait, preferably with stop motion video which allows us to slow down movements and assess subtle abnormalities that may not be visible during normal speeds of movement. If you are there for cycling orthotics, then a video of your stroke pattern is made. Sometimes, footage of your skiing technique can be helpful as well.

At this point, it should be obvious to both you and your orthotic provider whether or not an orthotic is needed. If so, a non weight bearing cast in terminal stance phase (This is a specific position of your ankle and foot) should be performed. This is usually followed by the prescription of appropriate stretches and exercises, specific to your condition. Shoe recommendations should also be given, since different foot types require different footwear characteristics. This will be good news for the ladies who like many shoes. Most guys just want the pain to stop and won’t care what they look like, as long as they are not pink!

Now you have an idea of what goes into (or should go into) building the perfect orthotic for you. Ask lots of questions of whoever is building them for you and make sure they are answered to your satisfaction. They should be a stepping stone to your recovery and  not a crutch for you to depend on. 

Telling it like it is, we are… The Gait Guys

Orthotics and Foot beds, What’s the Difference?

Orthotics and footbeds, they’re the same thing, right? This is a question that is often posed to us.  No, they’re not the same, but oftentimes one or the other can be appropriate. To explain the difference, we need to understand a little bit about foot mechanics.

The foot is a biomechanical marvel.  It is composed of 26 bones and 31 articulations or joints.  The bones and joints work together in concert to propel us through the earth’s gravitational field.  It is a dynamic structure that is constantly moving and changing with its environment, whether it is in or out of footwear.  Problems with the bones or joints of the foot, or the forces that pass through them, can interfere with this symbiosis and create problems which we call diagnoses.  They can range from bunions, plantar fasciitis, shin splints, TFL syndrome, abnormal patellar tracking, and lower back pain just to name a few.

Before we go any further, we should talk a little bit about gait (ie walking pattern). Normal walking can be divided into 2 phases, stance and swing. Stance is the time that your foot is in contact with the ground. This is when problems usually occur. Swing is the time the opposite, non weight bearing foot is in the air.

 

The bones of the foot go through a series of movements while we are in stance phase called pronation and supination. Pronation is when your arch collapses slightly, to make your foot more flexible and able to absorb irregularities in the ground; this is supposed to happen right after your heel hits the ground. As your foot pronates, the leg rotates inward, which causes your knee to rotate in, which causes your thigh to rotate in, which causes you spine to flex forward. Supination is when your foot reforms the arch and makes your foot a rigid lever, to help you propel yourself; This is supposed to happen when you are pushing off with your toes to move forward. It is at this time that the entire process reverses itself, and your leg, knee, and thigh rotate outward and your spine extends backward. When these movements don’t occur, or more often, occur too much, is when problems arise. This can be due to many reasons, such as lack of movement between your foot bones (subluxation), muscle tightness, injury, inflammation, and so on.

Many people over pronate, due to incompetence of the intrinsic musculature of the lower kinetic chain, genetics, environmental factors or injuries. This means that their arch stays collapsed too long while in stance phase, and they remain pronated while trying to push off. As we discussed, during pronation the foot is a poor lever. This means you need to overwork to propel yourself forward. This can create arch pain, inflammation on the bottom of the foot (plantar fascitis), abnormal pressure on your foot bones (metatarsalgia), knee pain, hip pain and back pain.

Lets look at skiing. Skiing is a stance phase sport. While skiing, your foot stays relatively immobile in a ski or snowboard boot (i.e. it is not moving through a gait cycle). A footbed is designed to create a level surface for your feet and keep them in a neutral posture. It accomplishes this by “bringing the ground up to your foot.” They are generally custom designed to an individuals foot through many different methods. They work incredibly well (as long as the foot remains in a static posture) and many people extol the benefits and improvements in their respective sports when using these.

Orthotics are always custom made devices. They actually improve the mechanics of your foot (or give you mechanics you didn’t have before) and make it function more efficiently by altering the shape and function of the arch as the foot moves through various activities. They act like a footbed but have the added benefit of functioning while dynamic (i.e. moving) as well. This works as well or better than a footbed, and is usable in other sporting activities, such as Nordic skiing, snow shoeing, hiking, running, or biking. Many people use their orthotic in their everyday shoes, to help prevent some of the problems and symptoms they are experiencing. It should be emphasized that an orthotic IS NOT a substitution for competent musculature. We view them as an aid to assist the rehabilitation process; slowly pulling out correction as the biomechanical competence improves.  We like to call this “Orthotic Therapy”.

In summary, a footbed supports the foot in a neutral posture. It is great for activities where your foot is static or held in one position. An orthotic supports the foot in a neutral posture and improves the mechanical function of the foot. It can be used in static or dynamic activities. Remember to always consult with a professional who is well versed with the mechanics of the feet, ankles, knees, hips and back, since footbeds and orthotics have a profound effect on all these structures.

Orthotics and footbeds; they can be great assistive devices along the road to foot competence. And they can be great doorstops when you are done using them!

We are and remain..The Gait Guys.

Research to support that we are on target !

CONCLUSIONS AND CLINICAL RELEVANCE:

The abductor hallucis muscle acts as a dynamic elevator of the arch. Understanding this mechanism may change the way we understand and treat pes planus, posterior tibial tendon dysfunction, hallux valgus, and Charcot neuroarthropathy. (see our video attached, it is much of what we talked about in this video just a few months ago).

*From the article: “Most studies of degenerative flatfoot have focused on the posterior tibial muscle, an extrinsic muscle of the foot. However, there is evidence that the intrinsic muscles, in particular the abductor hallucis (ABH), are active during late stance and toe-off phases of gait.

RESULTS:

All eight specimens showed an origin from the posteromedial calcaneus and an insertion at the tibial sesamoid. All specimens also demonstrated a fascial sling in the hindfoot, lifting the abductor hallucis muscle to give it an inverted ‘V’ shaped configuration. Simulated contraction of the abductor hallucis muscle caused flexion and supination of the first metatarsal, inversion of the calcaneus, and external rotation of the tibia, consistent with elevation of the arch.

http://www.ncbi.nlm.nih.gov/pubmed/17559771

Foot Ankle Int. 2007 May;28(5):617-20.

Influence of the abductor hallucis muscle on the medial arch of the foot: a kinematic and anatomical cadaver study.

Wong YS. Island Sports Medicine & Surgery, Island Orthopaedic Group, #02-16 Gleneagles Medical Centre, 6 Napier Road, Singapore, 258499, Singapore. yueshuen@yahoo.com

….well, some decent info here. But The Gait Guys are disappointed that there was no talk to dynamic evaluation of gait compensations and especially no talk of assessment for muscular inhibitions or weaknesses of foot controlling mechanics. Talked much about stability of the 1st MET, how about looking at the EHB, EHL, FHL, FHB function….to start !

Stress fracture factors guide orthotic choices