The most basic explanation is that ORTHOTICS attempt to control or adapt the physical alignment and function of feet in order to obtain the best possible performance from those feet (and therefore all other parts of the musculoskeletal system) which in turn will ultimately bring the most benefit to the individual concerned during the gait cycle/everyday activities.

Put simply, they are devices that are prescribed/adapted by the Podiatrist (after a biomechanical assessment of the patient both moving and stationary, weight bearing and non-weight bearing), which are placed in the patient’s footwear and are designed to correct any abnormalities that may be affecting the patient’s musculoskeletal system during locomotion. These abnormalities would most likely have been causing discomfort and/or wear and tear from which the patient would have been suffering hence them seeking treatment to try to alleviate the causes of the discomfort.

The first thing a podiatrist will seek to ensure is that the orthotic keeps the heel bone approx. 90 degrees to the vertical when stationery weight-bearing if this isn’t the case naturally, after that all adaptations (such as “postings” to e.g. the heel or forefoot area) to the orthotics will depend on the findings from the biomechanical assessment.

Some common foot conditions that often require orthotics are:

Flat Feet (Pes Planus) where the foot lacks a longitudinal arch (from heel to ball of foot) and the heel splays excessively outwards, so it therefore lacks the natural ability to shock absorb and provide a “spring in the step”. This sends shock waves back up the skeleton potentially causing ankle, knee, hip or lower back pain, it can also cause early wear on knee cartilage amongst other things. Orthotic therapy in such cases would be designed to provide a “false arch” to address the problems mentioned.

High Arch (Pes Cavus): Here the feet are excessively high arched and tend to be quite rigid in structure so therefore also suffer from an inability to soak up “shock”. The heels are also often “inverted” (angled inwards when standing) The foot tends to overload on the heel and forefoot and can give rise to severe callosities and corns. In such cases a cushioning element would be key as well as potential heel postings.

Morton’s Neuroma: A thickening or pinching of the nerves serving the toes (causing toe pain or numbness) that occurs at the area of the metatarsal heads, more usually but not exclusively in lower arched feet. An orthotic would probably have some kind of arch raise but would definitely incorporate a METATARSAL DOME which is a raised area that spreads the metatarsal heads so creating space for the nerve thus relieving any impingement.

Limb Length Discrepancies: Either occurring naturally or post joint surgery, a difference in leg length causes a pelvic tilt that therefore puts strain on the lower back and (often) the joints of the opposing leg. A difference of 2cm or above is reckoned to be the bench mark for problems to potentially occur so orthotics to address this would be advisable.

Other conditions including e.g. Posterior Tibial Dysfunction syndrome (causing drop foot and tendinitis), various sporting injuries e.t.c., are all problems that can benefit from Orthotic provision.

There are many causes of foot pain, some obvious and some not so obvious so probably the best thing to do is to make a list of some of the more common causes of foot pain:

OSTEOARTHIRITIS : A breakdown of joint cartilage and wear of the underlying bone that therefore inhibits and limits joint movement and function e.g. bunions

BURSITIS : Bursae are sacs of synovial fluid occurring naturally in the body where tendons cross bone, or are created by the body as a means of protection to repetitive pressure or friction on a bony prominence. They can become inflamed and therefore very painful and can sometimes ulcerate. Bunions and other prominent joints such as on hammer toes often have associated bursae.

CORNS and CALLUS : These occur over pressure areas on toes and on the soles of the feet. Callus is an area of hard dead skin, it occurs as a result of overloading or pressure on that area, it is painful because it is hard and inflexible and presses on the structures beneath. A corn is just a much more concentrated and hard callus at the centre of the pressure point, it can often involve nerve and blood supply.

INGROWN and THICKENED NAILS: Ingrown nails press into or pierce the flesh at the side of the nails and can become infected, thickened nails bruise the nail bed under the nail and can therefore cause bleeding and/or corns beneath the nail itself.

CRACKED HEELS/FISSURES: Due to an excess build up of dead skin due to pressure and friction or due to e.g. Psoriasis. They can open up so much they bleed or become infected or both. Fissures can also occur on the fore-foot usually around the ball of the foot on the under-side.

RHEUMATOID ARTHIRITIS: An auto immune condition where the body’s immune system attacks itself causing inflammation in the soft tissues of joints and ultimately causes joint deteriation/destruction.

GOUT: Too much uric acid in the blood causes intense swelling, heat, redness in joints, usually (but not always) the big toe joint. It is extremely painful. Repeat attacks can result in joint distortion and acid crystals being laid down in the joints.

METATARSALGIA : A blanket term for pain in the fore-foot. This could be caused by anything from metatarsal head fracture, Morton’s neuroma, interdigital bursitis to name several possible causes.

PLANTAR FASCIITIS: aka Policman’s heel, heel spur. Pain slightly to the inside centre of the bottom of the heel that sometimes radiates forward into the arch of the foot. Very much like a muscle strain but can’t heel due to never getting rested. Podiatrists have a variety of ways to get resolution but often orthotic therapy is needed to keep at bay long-term.

ILL-FITTING FOOTWEAR: Causes pressure or friction on various foot structures leading to e.g. Blisters, callus/corns, bursae, ingrown toenails.

CHILLBLAINS: Not so common these days due to more consistent heat via central heating, these are very painful areas where the tissue effectively dies because the circulation shuts down due to cold but doesn’t open up again readily so waste metabolites are left in the extremities of e.g. fingers and toes and so poison the tissues resulting in very painful bluey black areas of dead tissue. Reynaud’s phenomena is a major cause.

VERRUCAE: Can feel like corns, they are a viral infection that causes an area of skin to grow and die more quickly leading to callus build- up in that area.

STRESS FRACTURES: Can occur in any of the foot bones but usually in the metatarsals, usually due to over-use injuries.

This is by no means an exhaustive list but merely mentions some of the more common problems leading to foot pain.

INGROWN TOENAILS are potentially one of the most painful foot conditions that many of us may at some time experience and in severe cases will require surgery to correct, this can be done by your Podiatrist under local anaesthetic but here at INSTEP we only advise it as a last resort if it is apparent that no other treatment will solve the problem. During this procedure we take a strip of nail from the offending side so that aesthetically the best result possible is achieved for the patient as well as relieving the pain !

However, as with anything, prevention is better than cure so here are some guidelines to avoiding ingrown toenails:

1: Don’t cut nails too short, cutting back behind the front edge of the sulcus (trough at the side of the nail) can allow the front edge of the nail to grow below the skin line and thus press in at the front corner. Some nails have a natural inclination to curve in (involuted nail) so removing this front corner in cutting is necessary to stop pressure and in such cases you should only just nip the front corner off then file round so no sharp edge is left.

2: Don’t poke or cut a long way back down the sides, this is how small spikes get left that grow forward into the flesh.

3: Don’t pick, bite or tear nails, these all leave potential jagged nails that can grow in.

4: Some nails have a natural right to left/left to right curve across the front edge (if you look from above) so cut following this i.e. Follow the nail shape when cutting without going back down the sides then file the corners, this is basically “cutting straight across” as we have all heard, straight across the natural line.

5: Make sure your foot-wear doesn’t squeeze your toes.

6: Toe-protector foot- wear often damages nails, make sure the toe-box is deep enough so as not to exert pressure on the nails.

7: If for any reason a toe-nail starts to hurt, get it looked at sooner rather than later as it will be quicker and less painful for your Podiatrist to deal with if caught early.

Unfortunately some people will be genetically predisposed to “curvy” or “involuted” (potentially in growing) toe-nails and it might be advisable for them to have their nails cut professionally so as to avoid problems going forwards.

DO I SEE A GP BEFORE A PODIATRIST ?

This would depend on the nature of the condition that the individual is seeking advice or treatment for, but there are some cases where it would be fair to say that the Podiatrist would be the first choice whilst in other cases the GP should be consulted first.

All GP’s will have a particular specialist area and also a broad knowledge base about a massive amount of other medical conditions but one shouldn’t expect them to be as well versed as any particular health professional who has trained and practices daily in one specific discipline. That is why if you do use your GP as a “first port of call” they will often advise that you seek treatment from the relevant health professional that they feel would best be suited to your particular complaint.

Below are several examples of perhaps “PODIATRIST FIRST”:

If a person were suffering from a suspected INGROWN TOENAIL then it would be far better to see the Podiatrist, more often than not GP’s will prescribe antibiotics and say that will do the trick which unfortunately not true. Whilst the antibiotics will quell any infection in the short term, the nail will continue to grow and pierce the flesh so the problem gets progressively worse in the medium term and if infection returns before the problem is resolved then the patient will need more antibiotics before the potential minor surgery under local anaesthetic can be performed. Incidentally surgery is the usual final outcome due to the delay and resultant increase in pain etc..

Corns/Callus : No need to bother the GP with this, it basically needs removing by the Podiatrist.

Orthotic provision : A podiatrist should be specifically trained to analyse gait problems and have the ability to prescribe the right orthotics for the condition presented. Often we receive referrals from other health professionals such as Osteopaths and Physiotherapists who have realised there is a gait problem causing a knock-on effect further up the frame and want us to have an in-depth look and prescribe accordingly.

VERRUCAE: At one time GP’s often ran Verruca or Wart clinics but this isn’t often the case now so better to visit a Podiatrist for diagnosis and treatment.

PLANTAR FASCIITIS: GP’S will often prescribe anti-inflammatory medication and maybe suggest cortisone injections, there is nothing wrong with this approach except that cortisone only masks the problem for a while but it doesn’t usually cure it. This condition needs more detailed treatment and advice for both the cure and future prevention so ideally the Podiatrist would be the first port of call.

Instances where the GP would be the best initial option would be for example in cases such as potential melanoma or deep vein thrombosis. These types of problem definitely warrant confirmation or referral via the GP to the appropriate specialist consultant who would then instigate the appropriate treatment. That is not to say that we as Podiatrists cannot identify these types of problems correctly, we often do, but even then our course of action would be to direct the patient towards their GP for confirmation and referral.