The Clinical application of Podiatric Biomechanics

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The Clinical application of Podiatric Biomechanics

• David N Dunning
• DipPodM. MChS. MSc. PGCert.(sports pod)

www.dunningandtrinder.co.uk
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Aims of podiatric management

• Every facet of upright activity is a
  biomechanical event.
• As we have seen the foot is designed to take
  stress.
• The objective of any treatment intervention is
  to
• Reduce the stress on the structures to an
  acceptable level.
• Return the limb to as close to normal as possible

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Pronation

• Pronation is good
• Excessive pronation is bad
• Lack of resupination is very bad

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Pronation

• Pronation Abduction, Eversion and
  Dorsi-flexion
• Supination Adduction, Inversion and
  Plantar-flexion
• What are the main shock absorbers?

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Management options

• 1st Aid (R.I.C.E.)
• Drugs
• Physical therapies
• Orthoses
• Footwear
• Exercise
• Advice
• Surgery

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Rest Ice Compression Elevation

• Rest if possible. In some conditions some pain
  is acceptable to the committed athlete.
• Ice in the acute stages.
• Compression not always easy to do.
• Elevation following activity. (Whilst icing)

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Drugs

• The use of steroid injections is very useful in
  some cases but for instance in Achillodynia they
  are to be avoided as they have been associated
  with spontaneous rupture.
• NSAIDs can be useful. But there is evidence that
  there long term use can delay the healing
  process.
• (Elongates the Regeneration phase)

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Physical therapies

• Frictions and mobilisations, but not in the acute
  phase
• Ultra sound etc. this can enhance the
  inflammatory process thus reducing the lag time
  to the next two phases.
• Stretching and strengthening.

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Orthoses

• There are many different types.
• Not just medial wedges.
• Tri-planar (casted) devices.
• Preformed (non-casted) orthoses
• Must be used in all shoes?
• More later

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Footwear

• Shock absorption good or bad?
• Rear-foot control.
• Heel tabs.
• Must be stable Muscle conflict.

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Exercise

• Stretching involves-
• Keeping the Tri-ceps Surae group functional
  through its full range.
• Therapeutically re-organising the fibres of both
  muscles to help in rehabilitation.

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Eccentric exercises.

• Eccentric muscle action contraction whilst
  lengthening.
• Plyometrics hopping, bounding or depth jumps
  ???
• (Are these types of exercise really appropriate
  for structures that may be in a weakened state???)

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Advice

• Change activity where possible.
• Look closely at all footwear.
• Fit for purpose

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Foot orthoses

• The functional foot orthosis is an orthosis,
  which is designed to promote structural integrity
  by resisting all stance phase forces, that would
  cause abnormal skeletal motion or position, while
  allowing normal motion during the stance phase of
  gait.
• William P. (Bill) Orien (2001)

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The orthosis must

• Support any forefoot deformity that would exert
  an abnormal retrograde force on the rear foot
• Resist abnormal extrinsic or intrinsic forces
  that would cause excessive medial or lateral
  distribution of weight into the rear foot,
  causing abnormal sub talar joint and mid tarsal
  joint pronation or supination during the time of
  gait that the heel is bearing weight

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• Promote normal rear foot pronation during the
  contact period of gait for shock absorption and
  assist in re-supination of the foot as it moves
  toward propulsion. Resist forces that promote
  abnormal pronation of the rear foot during the
  stance phase of gait.

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A non-functional foot orthosis

• The noun orthosis is derived from the Greek
  Ortho- meaning to correct or straighten.
• The standard arch support of old can not be
  referred to as a foot orthosis unless it
  straightens or corrects an abnormality. Generally
  the material is too soft to resist ground
  reaction forces, or if it is of a hard material,
  because of its position, it would be too
  uncomfortable to wear.
• FHL Either the foot hurts or the back hurts!!

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Pre-formed or non-casted devices.

• These are foot orthoses that have a functional
  element yet are not made from a positive cast.
• Bearing in mind Dr. Oriens definition then if an
  off the shelf device can achieve these aims it
  can be referred to as functional

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A functional device should-

• Support for forefoot anomalies.
• Resist forces acting on the calcaneus.
• Provide shock absorption.
• Provide for normal function.
• Fit well.
• Be manufactured with the appropriate
• materials.

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Preformed devices.

• Vectorthotic is just one example
• Soft EVA cover.
• Hot glue stick on forefoot posting
• Marked for 1st ray cut out.
• Hard but heat mouldable shell.
• Clip on rear foot posts.

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Foot orthoses

• Control the mechanics of the foot and lower limb

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Slipper casts
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Foot orthoses and shoe adaptation go hand in
glove

• Excuse the expression

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To recap-

• Treatment options.
• Advice
• Physio, drugs etc.
• Strapping short term
• Serial casting
• Temporary orthoses
• Preformed, work shop manufactured
• Balanced (casted) orthoses
• Footwear
• Adaptations, Modular or bespoke
• Surgery

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Case histories

• FHL
• Bunnions
• Achillodynia
• Heel spur syndrome
• Metatarsalgia
• Diabetes
• RhA

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