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Orthotics for TTS

Posted by Scott on 4/27/03 at 08:22 (117213)

Can orthotics help if you have tts? I was told by a pt that an othotic wouldn't help any nerve problems but my podiatrist told me that my ankle rolls inward and that orthotics may help. I know I walk on the outsides of my feet because my shoes are worn on the outsides.

Re: Pronate or Supinate?

JenL on 4/28/03 at 10:38 (117260)

Scott,

You have to look at the cause of TTS, I guess. IF it's related to PF as some people on the board do, I think wearing a good orthotics can certainly help. Generally, well fitted orthotics can enhance health of feet even if there is no painful condition.

I don't understand that how your ankle rolls inward while you walk more on the outside of the feet? You overpronate when your ankle rolls inward too much, right? My husband's shoes are worn on the ousides too, and I think that's supinating. I try to figure out the potential foot problem if any.
Thank you or anyone contributing to the question.

Jen

Re: Pronate or Supinate?

Jean on 4/29/03 at 09:45 (117334)

I have flat feet that roll inward, but to compensate,I walk on the outside of the feet.My shoes wear out on the outside, contrary to popular wisdom...

Re: Pronate or Supinate?

Dr Kiper on 4/29/03 at 11:27 (117337)

You have hit the nail on the head. Wearing orthotics that fit well is tantamount to brushing your teeth for prevention of cavities, not curing them. Orthotics minimize the repetitive action of the arch which is responsible for slowing down the natural process of wear and tear. If one is fortunate enough (predicated on a host of factors), a proper fitting orthotic 'may' prevent not only serious biomechanical problems but may even prevent minor problems as well despite the mileage over a lifetime.
I compare every decade of life like a car that's gone 100,000 miles. Sooner or later somethings gotta give.
The problem for most people is finding an orthotic that is comfortable and easy to wear, therefore they do not reap this benefit.

As to pronation/supination: everybody pronates (including supinators), it's just that supinators pronate less. Most people wear out the outside part of the heel because that's the angle at which the heel strikes the ground (regardless of being a pronator or supinator). People who wear out the outside (lateral edge) of the entire shoe are supinators.

How do you tell if you are a pronator or supinator? It's simmple:
pronators are flat footed
supinators have an arch (even if it's minimal).

Re: Need Pronation Control?

JenL on 4/29/03 at 16:26 (117370)

Ok, everyone pronates! It means that we all roll our ankles inward when we shift body weight from the heel to the forefoot, and in other word pronating is NATUAL?! Some people just pronate within a certain range that it's not bad enough to cause problems; while other (a small number in comparison) developed PF and other conditions because they pronate too much. This raised a question about the motion/pronation control by some shoes, like New Balance. Is it necessary to control or stop the pronation for everybody? I have tried NB shoes for two days and they are very rigid, and uncomfortable. Surely my feet cannot roll at all in them. At the same time my feet feel terrible because I think the natural movement is interrupted. Besides I am not sure if my heel pain is caused by pronating or not. Even if it's, I feel this kind of control hardly works for me.
I appreciate your input on this.

Jen

Re: Need Pronation Control?

Dr Kiper on 4/30/03 at 10:35 (117429)

The normal motion (of pronation)is that ankles do roll inward, BUT it doesn't mean they roll 'visibly' like a flat footed person.

Yes, pronation is normal and overpronation is normal. EVERYONE overpronates as well (including high arched supinators), what is not well understood is that overpronation simply means that the range available in THAT foot is using ALL the pronation it has to absorb incoming shock ( pronators have a larger range of pronation thasn do supinators) Running hyperpronates that available range of pronation.

It is the constant repetitive motion of that arch moving up and down 100's to 1000's of times per day that results in that injury (when it comes to the surface--ouch!)

Therefore everyone is vulnerable to injury at some point in their lifetime. Believe me, there is hardly a person on the face of the earth that doesn't experience some kind of pain in the lower extremity (due to pronatory forces) at some point in their life.

For those that don't have problems that you are aware of, will probably eventually come to the surface. It's kind of like someone who's had a heart attack by age 39 and wonders why someone they know 70 yrs old has never had a heart attack. Well, if that 70 yr old person lives long enough and doesn't die of some other cause, they will die of a heart attack. There are so many beats available to you in your lifetime, no one knows just how many.

You cannot compare your injury to anyone elses, there are too many factors involved here to even list.

Now the most important thing you stated about the 'motion control' is right on the money.
First you don't 'stop' pronation. And 'controlling' it with either motion control shoes and traditional orthotics (in my humble opinion), is the problem.
pronatory forces need to be 'minimized' so the foot can act like the shock absorber it was intended. Meaning limit, the 'overpronation' to an efficient range of motion. This allows the mechanics to work 'optimally', it does not mean you still can't get an injury. Even a car that is running at 250,000 miles can be fixed up, but it still has 250,000 miles and is 'vulnerable' to reinjury or NEW injury.
Again depending on a variety of factors, some people do extrememly well and others still get injured.
A traditional orthotic does not allow the foot to work in its optimal position most of the time, because it 'controls' the foot through its footstep, holding it to a preset position determined by 'custom molding'.
What is needed is an orthotic that 'guides' the foot through it's footstep, determining it's own best (natural) position on the ground.

In all likelyhood, your heel pain is coming from a lifetime of repetitive movements (pronation), however there can be other causes (metabolic, organic etc--talk to your own doctor about this).

Re: Pronate or Supinate?

BGCPed on 5/01/03 at 00:47 (117511)

Some good points but I would submit that the 'arch' is not the end all and be all of causative factors in foot conditions. There are several planes and segments of foot function that have an affect on each other.

Not every person pronates. An example would be post polio with tight gastroc, equinus, genu recurvatum and tivial varum. They dont even come close to pronation. I dont think all the focus is on the function or range of the medial arch. the foot is more complex than just trying to control the arch.

Just throwing out an opinion

Re: Pronate or Supinate?

Dr Kiper on 5/05/03 at 06:03 (117822)

I'm sorry that you didn't give any 'examples' of other causative factors due to planes and segments of foot function, because I don't know if I would agree with you.
The focus here is the majority. Polio has been wiped out, with the exception of a few places in the world, I doubt they are even reading this post. When you do give the example of post polio NOT pronating it may be the one example that I may agree with, but not everyone with post polio doesn't not pronate either. As for tibial varum and genu recurvatum, I disagree with you. Pronation begins at the talo-navicular joint. Any motion, ANY, there is pronation. The ONLY way you cannot have pronation is if you have a rigid foot with total arthrodesis (fusion).
In addition, any joint not fused also allows pronation, and that too then is vulnerable to pronatory forces over time.

Re: Pronate or Supinate?

elliott on 5/05/03 at 16:25 (117842)

Dr. Kiper, your key point as to why a traditional orthotic is inferior to your own is that many find it uncomfortable at the arch due to its being rigid, in contrast to the gliding comfort provided by yours. Question:

If someone finds a traditional rigid orthotic to be very well-fitting and comfortable but yet it doesn't 'cure' him of his ailment or at least alleviate the problem to a satisfactory degree, is it safe to say that under such circumstances there is no point in trying your orthotics?

Thanks for your input.

[][]

Re: Pronate or Supinate?

Dr Kiper on 5/05/03 at 19:14 (117851)

This is a very good question. Ordinarily 'any' orthotic that fits well and is comfortable should provide reasonable if not excellent results. BUT, the one criteria a traditional orthotic does not meet is that it does not match the way that foot works (to its optimal position in function). In other words, pronation being 'normal' is a dynamic shock absorber. A traditional orthotic cannot match the 'dynamics' of the way that foot walks. The fluid acts as a decelerator to the pronatory action and cushions the end of the range of motion to minimize overpronation, thereby acting like it's part of that foot. This can make the difference between satisfactory and excellent results, in my opinion.
Should someone try it on that basis, why not? The opportunity to do so is risk free, so they have nothing to lose if not satisfied.

Re: Pronate or Supinate? Clarification of terminology

Ed Davis, DPM on 5/05/03 at 20:25 (117859)

Jen:
I think I need to step in here for the purpose of clarifying terminology.

When the foot stikes the ground, the heel always hits on the outside first, rubbing away some rubber from the outside, back of the heel. That is why shoes wear on the outside of the heel.

Once the foot has struck the ground on the outside of the heel, the foot then rolls in (pronates). Pronation is a normal manifestation of gait -- it is the manner in which the foot rolls in and a means of absorbing shock.
Shock from the initial heel strike is converted to a rotary type motion occurring at the joint between the heel bone and the bone above it, the talus (AKA, the subtalar joint). We are concerned about overpronation -- too much pronation or pronation which is too fast at the SUBTALAR joint.

When the rearfoot or heel is rolling in (pronating) the front of the foot must move in the opposite direction. That occurs via supination at the midtarsal joint. The action of subtalar joint pronation and midtarsal joint supination causes elongation (and possibly strain) on the plantar fascia. Subtalar joint overpronation and midtarsal joint oversupination are what strains the plantar fascia. These motions occur in sequence but overlap so referring to a foot as rolling in too much or rolling out too much is only half of the story.

I can understand how the SDO's can decellerate subtalar joint overpronation but their effect on the midtarsal joint is not clear.
Ed

Re: Pronate or Supinate?

BGCPed on 5/05/03 at 22:40 (117875)

Well post polio is an example I used to make a point. There are still many around and I dont see why they would not be at this site. I would assume you are familiar with the procedures done on the foot and the common equinus that resulted in varus and degenerative knee from recurvatum. Not to mention inversion instability. You supported my point by saying that ALL post polio doesnt pronate either.

You also pointed out that the main focus here is 'the majority' that is also subjective and if your device works on the same dynamic fluid principle it should work for all foot types equally. The words prontaion and supination are often overused and incorrect. If the purpose is to support the arch in majority of cases to control pronation then I am not sure I get it.

I was looking at some pressure plate studies on the silicone device (not sure if it was your site or ez runner) and it had a flaw in my opinion. Under the 'supinated foot' examples it compared silicone device with a 'traditional' cavus orthotic. It used pressure readings to illustrate function and efficacy of orthotics. The silicone device , since it is flat bottomed showed colors and pressure over entire area. The failed supinator traditional orthotic showed no color i.e. pressure under the arch.

That would be expected since many traditional orthotics made of more rigid materials would not show any pressure under midfoot since they are rigid and elevated. The pressure plates are located under the orthotic in the shoe, so the traditional orthotic would not come in contact with the sensors. I would say that is not a flaw in the traditional orthotics but rather a shortcoming of the testing device.

Another point, the supinator pressure reading also showed a region of very marked pressure proximal to the 1st mtp. I was not at the test but I would bet that it was pressure from a post behind the 1st mtp, and I bet it was varus. I treat probably 3 to 5 cauvus feet per day and I see no functional reason for any post like that behind the 1st. Furthermore I get probably 10 failed orthotics per week on cavus pt that have a varus ff post and or no cutout for the 1st to drop down, 99% supinators have some degree of plantarflexed first ray, it cant push through the floor so what happens to that foor type in your device?

Re: Pronate or Supinate? Clarification of terminology

JenL on 5/07/03 at 08:55 (118001)

Thank you all! Some of the terminology are beyond my layman's vocabulary, but I am getting the basic ideas. Boy, how complicated our feet and its motions are!
Jen

Re: Pronate or Supinate?

Dr Kiper on 5/07/03 at 09:41 (118007)

I cannot believe that you stated 'then the fluid principles should work for 'all' foot types equally'. I almost don't know how to respond to this.
I never said it would. I never stated that one orthotic can meet the needs of all people. For example, a patient with cerebral palsy could not even get their shoes on with anything other than an AFO, and then it's difficult for them.
The 'majority' I refer to may be subjective in your opinion, but the majority of people anywhere are just individuals with 'normal' pronatory force problems accumulated over a lifetime. Handicapped and/or severe biomechanical deformity are not what I'm addressing. I would have to see the individual and their condition personally before I could say I can help, and chances are I would not be able to help the 'majority' of them.

As for your not 'getting it to control pronation' with fluid principles, you are not alone. This is the problem with most all of my colleagues. The paradigms of 'rigid control' are very difficult to overcome. Together with the original inventor of the silicone orthotic, probably close to $50,000.00 to bring it to the forefront of our profession, seminars, and vendor booths at major seminars around the country, I am tired of trying to convince, sell and educate my colleagues. When I explain it to everyone else (the majority as it were), they all say 'it makes sense'.

I don't have the time or inclination to explain the physical principles involved in fluid mechanics, I suggest if you are interested, research the
following:
Pascal's Law of Gas and Fluids
Archimedes Principle

Sorry I can't be more cooperative, but I am a two finger typist at best and cannot delve into the verbal imagery it would take especially on a one on one basis.

Re: Pronate or Supinate? Clarification of terminology

Dr Kiper on 5/07/03 at 10:43 (118013)

Jen, it's only complicated to the people in my profession and all allied professions that deal with this, believe me it's really very simple.
Think of the foot (which is the foundation to the lower extremity), as a mechanical device like a shock absorber on a car.
It moves up and down hundreds and thousands of time/day. Over the course of time and god knows how many miles, these 'devices' wear and tear to the point of breaking down. Now metal, is easy to fix. Living tissue involves more. It takes time to reverse the microscopic damage that occurs.
Couple that with the fact that even if you are in biomechanical pain, you still have a life to live. Work, school, household and even walking into the kitchen to get a glass of water. Every step you take antagonizes the problem. Even with a proper fitting orthotic it's still two steps forward and one back. You want to get better faster, go to bed and stay there for the next 4-6 months, I personally guarantee you will get better and pain free. 'If' you can't do that, then the alternative is to find someting that improves the efficiency of the condition that causes the problem(s).
The underlying condition of lower extremity biomechanical pain (for the 'majority') is the up and down repetitive motion of the arch.

Now just a little background, the arch moves up and down as far as necessary (and when running, as far as it can) to absorb incoming shock. The allowable range of motion that the arch travels is pronation (and supination, but pronation is the destructive force). When that arch reaches the bottom of its 'allowable range of motion', this is overpronation (regardless of walking or running). This repetitive overpronation over time is the cause of your pain(s). So to fix this living tissue, we need to place something under the arch that 'minimizes' this overpronation. This in effect will slow down and reverse years of accumulated damage. How long will that take, I don't know, if I did, you'd see me on Oprah.

But this I do know, if that device under your foot, fits 'properly' then you are healing, despite the fact it may take a long time to even begin to feel positive effects. This is the biggest cause for failure with patients in 'chronic' pain. They become impatient and frustrated and discouraged, that things are not happening quickly enough.

So now you have to ask 'how do I know it's fitting properly'?
Simple again, it must meet 4 criteria;
1-you have to feel the support
2-it 'MUST' be comfortable (or tolerable, because sometimes your neuro-muscular senses are too distorted to feel 'comfort', so as long as it doesn't create new problems, it meets the criteria)
Too often patients wear an orthotic that helps, but is not comfortable, in order to get the maximum benefit, it must be comfortable.
3-you must feel stable on the ground, if you feel slightly over on the outside edge of your foot, you are overcorrected. Again you may even feel some improvement, but you are not getting the max benefit.
4-it must match the way your foot walks. A correct prescription is not one that fits the neutral position of your foot or the shape to which it was custom molded. Because your musculature may not be ready to walk in a new position that it has been used to for so many years.

I let the patient dictate based on certain subjective feelings that the orthotic is matching the way they walk, or I adjust the prescription accordingly. The difference (and advantage) with the fluid orthotic is that as soon as you change any volume of the fluid, it automatically changes the structural position of the foot to the ground (this is predicated on laws of physics). You cannot do that (in most cases) with a traditional orthotic, because the position is structurally 'set'.

Lastly, remember that no matter what, it takes time to heal. I like to tell patients that even if you turn off the flame under boiling water, and it stops boiling, you cannot touch it for awhile for risk of being burned. And if you turn the flame back on (like walking around), it doesn't take long to get back to a 'boil'.

Your painful inflammation is like that, it has reached a 'boiling point' that reaches a critical level resulting in pain. If you've been neglectful in trying to get help, if help has been unsuccessful, then you will become part of the many people who become 'chronic' and talk about OTC orthotics, custom orthotics, therapies, modalities, injections, strappings etc and all the things you've tried and failed.

Keep looking for things you haven't tried, maybe something will work.

Re: Pronate or Supinate? Clarification of terminology

Ed Davis, DPM on 5/07/03 at 11:02 (118016)

Dr. Kiper:
I had queried the effect of SDO's on the midtarsal joint my post above. What are your thoughts on that?
Thank you.
Ed

Re: Pronate or Supinate? Clarification of terminology

Dr Kiper on 5/07/03 at 14:14 (118029)

I do not want to get into a discussion about your technical question here. Because of the difference in our biomechanical understanding one answer will only prompt another question and so forth and so on. It's not important information for the general population here, And even if several are interested, I don't have the time. what matters is does it work.?
E-mail me through my www and give me your phone # and best time to call and I'll be happy to discuss it with you, it's easier for me to give you an hour of my time that way then trying to type that volume of information in.

Re: Pronate or Supinate?

BGCPed on 5/07/03 at 21:39 (118070)

Pascal's Law, in simple analogy. If you filled a ziploc baggie with pudding. And you push down on it with your finger the pudding will flow away at equal rates and pressure. Laws can be applied to anything but the existence of a law does not automatically legitimize all claims.
Claiming that most all cases are a result of repetitive movement of the arch going up and down, and that limiting the down motion, is rather broad in my opinion.

If you have the time could you address my question regarding the pressure readings posted for the cavus foot with a traditional hard device and the gel device?

Re: Pronate or Supinate?

Dr Kiper on 5/09/03 at 14:33 (118189)

I feel you've proved my point with your bag of pudding, although fluid is the better medium:

'An increase in pressure in an enclosed envelope is transmitted uniformly and instantaneously to all portions of that envelope' (Pascal's Principle).

My claim is when the foot makes full contact with the ground (starting with heel strike), the pressure against the envelope is uniform and redistributes the high and low pressures of the foot equally, and this principle does NOT apply with a traditional orthotic.

So, the law applies, it does legitimize the claim.

Now as to my statement of biomechanical problems secondary to the 'up and down' movement of the arch, you're entitled to your opinion that it is 'broad'. Mine as I see it is simple and narrow for the 'majority'. Biomechanical problems such as foot, knee, hip and low back are (by and large) repetitive injuries and yes there are additional complex factors.

There is nothing more repetitive then the arch moving up and down which transmits the repetitive action to the tissues involved in the injury.

I'm trying to keep this simple for the general population. While some are more knowledgeable than others and may follow our context, I do not believe this is the forum.

It invites too many others to interpret our dialogue and more questions, and I don't have the time to get this involved, especially one on one. Anyone interested in a personal consultation (at no charge) can contact me through my web site.

As to your query about the pressure readings for the foot scan, I'm not sure what you're asking and which scan you're referring to. If you wish to copy and paste it to the board, I'll try to address it for you.

Thereafter, since I'm not trying to convince you or anyone of anything, I prefer to answer questions by the people who are having problems. It is for them to decide what makes sense and if they want to try something new.