Burning Soles: A New Kind of Hell


 

Burning feet are a common presentation in both private and public practice. The reason for these symptoms can be one of many and in a lot cases can be a combination of factors leading to the infliction of this hot foot phenomenon. Vascular, neurological and dermatological influences can contribute the perceived foot temperature, all of which themselves are effected either directly or indirectly by a number of life choices, disease or deficiency. The following article is a look at why these symptoms may be causing discomfort.

Neural
Peripheral Neuropathy is the most common cause of burning for burning pain in the feet, it is the damage of a nerve fibre anywhere along its pathway from the spinal cord to the nerve ending. There are a number of reasons for the development of Peripheral Neuropathy with diabetes being identified as being a major national health issue at this time. The consistently high blood sugar levels in diabetic patients damage the blood supply to the nervous system interrupting the transmission of signals to and from the feet. Symptoms will commonly beginshutterstock_52270414 with the feeling of numbness, muscle weakness and tingling in the feet and lead to burning which becomes worse during the evening.
Other causes of peripheral neuropathy include shingles, various medication, chemotherapy and secondary injury.
Charcot-Marie Tooth Disease is an inherited genetic mutation disorder which affects a number of nerves. Burning feet can be accompanied by drop foot, poor balance and numbness.

Neuroma’s are the result thickening tissue surrounding the nerves within the foot. More specifically a Morton’s Neuroma is the thickening of nerve tissue between the 3rd and 4th metatarsals of the foot. The cause of this pathology can be one of many but most commonly is inclusive of; repetitive stress from high impact activities, foot deformities or increased compressive pressures. Presenting complaints are most often described as burning pain and feeling like stepping on a pebble.

Tarsal Tunnel Syndrome results from the compression of the tibial nerve inferior to the medial malleoli as it passes through the tarsal tunnel. This presentation will commonly occur unilaterally and present as burning of the feet and pins & needles in the sole.

Other neural conditions which may lead to the burning feeling felt within the feet include Chronic Regional Pain Syndrome and Grierson-Gopalan Syndrome, two topics which deserve their own articles perhaps later in the year.

Vascular
Peripheral Vascular Disease (PVD) and Peripheral Arterial Disease (PAD) are obstructions of the blood vessels of the extremities such as the feet. Vascular Diseases such as this are cashutterstock_309584594used by narrowing of blood vessels, thickening of blood vessels or a complete blockage leading to a compromised blood supply. The poor circulation of blood supply to the feet causes a patient to develop burning feet, tingling and pain, most commonly during activity and will reduce at rest. Signs that vascular disease may be present or beginning to take effect include feet and legs
feeling cold, skin weakness and breakdown (which may lead to ulceration) and reduced hair or nail growth on the legs and feet.

Another vascular contributor to the feeling of burning feet is a lesser known condition, Erythromelalgia. Erythromelalgia is a rare neurovascular disorder resulting in the intermittent blockage of blood vessels. The most common sign for this particular condition is the redness, swelling and burning foot pain. Early diagnosis and management is important as long standing symptoms can lead to longer term damage.

Additionally, other conditions such as blood vessel inflammation (vasculitis) and heavy metal poising can also be contributing factors to the feeling of burning feet.

There is a many different diagnosis which may contribute to burning feet. Vascular and neural elements are the two major instigators however, fungal infections such as tinea pedis (athlete’s foot) and serious disease or medications can also bring on such symptoms also. This is why it is of the utmost importance to seek advice from your medical or allied health professional when these symptoms present.

Until Next Time

Jackson McCosker
Director/ Chief Editor

Medial Collateral Ligament (MCL): Overview


The Medial Collateral Ligament (MCL) comprises of both a superficial and deep portion, which work as medial knee stabilizes. In the United States MCL injury is seen to be rare with it only effecting 1 in 4000 athletes, typically occurring in sports such as skiing, ice skating, hockey and soccer. Majority of complete tear (grade III) MCL injuries will heal, however, if they are not rehabilitated appropriately will lead to a chronic knee instability.

shutterstock_277232012The largest and important structure in the medial knee is the superficial MCL originating at the femur and inserting at two tibial anchor points which functionally act in different ways. Being aware of this anatomical structuring is important as instability can be seen with external rotation, valgus rotation or anteromedial rotation.
The deep MCL does not have a distinct structure, it is a thickened joint capsule deep to the superficial MCL.
MCL injury mechanism is typically associated external tibial rotation, valgus knee loading or a combination of the two leading to forces placed upon the knee which are above that which the body can tolerate.

 

Grade I – no significant medial compartment gapping, localized pain along the medial knee.

Grade II – significant gapping at the medial compartment with a definite end point and localized pain.

Grade III – No defined end point after application of valgus stress at 20deg of knee flexion

Rehabilitation
With the stronger evidence for pre-operative rehabilitation also came the development of more aggressive post-operative rehabilitation as opposed to the previous conservative approaches. Similar to the aims of the pre-operative rehabilitation programs, post-op programs aim to strengthen the knee joint and improve the proprioception around the joint. The most successful rehabilitation programs have been those which in compass home based activities and clinical setting elements. As well as the utilization of both open and closed chain activities specific to the muscles cross the knee joint.

There are multiple intrinsic and extrinsic factor which may impact an athletes return to sports however; most are expected to return to training in 6 -12months. A phased rehabilitation MCL program my look similar to the following:
PART ONE: Reduce swelling, return to full weight bearing and increase passive knee range of motion.

PART TWO: Improve proprioception, increase muscle strength in the quads and hamstrings while increasing passive knee extension.

PART THREE: Achieve better neuromuscular control and optimal strength within the lower limb.

PART FOUR: Return to sport specific exercises, movement patterns and multi-tasking activities while maintaining and improving stability of the knee through proprioceptive exercises.

 shutterstock_195284591Operative Treatment
Acute injury associated with the MCL is indicated with knee dislocation or malalignment injuries and requires the direct repair of injured structures using sutures or a complete hamstring graft in reconstruction of the medial knee stabilizers.
Alternatively, those who present with chronic medial knee instability symptoms are required to undergo a number of operations including a femoral osteotomy to reduce the risk f over stretching the reconstructed ligament that will eventually be put in place.

It is important to realize that pre-injury functional limitations may still be present after rehabilitation has been complete. Medial knee instability should be both clinically and objectively assessed in any patient who has a suspected MCL injury. If instability is still present, then the use of surgical intervention and anatomical reconstruction is highly recommended.

References

Labanca, L., Laudani, L., Menotti, F., Rocchi, J., Mariani, P., Giombini, A., . . . Macaluso, A. (2016). Asymmetrical Lower Extremity Loading Early After Anterior Cruciate Ligament Reconstruction Is a Significant Predictor of Asymmetrical Loading at the Time of Return to Sport. American Journal of Physical Medicine and Rehabilitation, 248 – 255.

Laprade, R., & Wijdicks, C. (2012). The Management of Injuries to the Medial Side of the Knee. Journal of Orthopaedic & Sports Physical Therapy, 221 – 223.

 

 

Running Myths: Commonly Touted Alternative Facts by Non-Runners and The Easily Excitable


 

 
When I was running regularly I used to read every article in Men’s Health, Men’s Fitness, Runners World and Run4Life with devotion and interest as if it was gospel. Before learning to look at things with a little more analysis and tact I believed that if it was to be published in such a reputable magazine it must be true, it must be checked and agreed upon to be correct.
No, in fact if many times if you truly look at these articles the publishers have grabbed one sentence, out of context from a journal of sports or medical research and used that line to spark conversation and debate. These sentences then get passed around as fact or stories by other runners between one another until it becomes a new fad.
Additionally, those who do not understand or enjoy running also manage to let you know the “facts” they have heard about running which they may have picked up from a current affairs news show or pop-culture magazine. I’ve heard quite a few myths over the years, “you’ve only got so many heart beats”, “my friend used to run a lot and now he needs a knee replacement” and “barefoot running is the natural way”.

  1. Forefoot strike creates less injury riskshutterstock_265190498
    I think Craig Payne said it best when it comes to statements such as this “different running techniques load different tissues differently.” In other words, if you are someone who suffers from chronic knee pain as a result of running, forefoot strike may be appropriate for you to try due to a decrease in stressor placed upon the knee and an increase of stressors on the ankle joint. However, doing so loads up another region of tissues which may not be able to handle the sudden increase of expected force and also lead to injury. Additionally, it is not a reliable practice to predict specific injury of an individual based on their biomechanics. Biomechanical visualisations can be flagged as a risk factors for injury but they are not able to define the tissues ability to cope with that highlighted risk factor.
    Further information can be found here about this topic:
    https://footnotesblogging.com/2015/01/01/foot-strike-pattern-and-associated-injuries/
  2. https://footnotesblogging.com/2016/03/09/foot-strike-pattern-during-running-and-athletic-performance/
  3. https://footnotesblogging.com/2014/09/25/90/

 

  1. You should always stretch before running
    If you are stiff before going for a run light stretching may be beneficial to help lengthen muscles and reduce adhesions from restricting range of motion. However, static stretching prior to every run can be reduce efficiency in the ability of tendons and soft tissues to produce and release stored energy. A more effective approach in reducing injury risk is to complete a dynamic warm up routine and activation exercises focusing on the muscles which you plan to use within your upcoming training session, specifically the gluteal muscles.

Further information can be found here:
d. https://footnotesblogging.com/2015/10/01/tight-knots-and-stiff-muscles-a-look-at-myofascial-release/

 

  1. The more you run the better you run
    The more you run the easier it becomes due to the physical and physiological adaptions of the body, but no it does not make you a better runner. In fact, completing faster sessions with shorter duration not only reduces your chance of injury but can increase your performance as well. Yes, of course completing slow long distance runs are beneficial when building endurance specific to an event but in the interest of doing it in a sustainable way short fast sessions are best.
    Read more about this below:
    e. https://footnotesblogging.com/2017/02/28/prevention-vs-performance-managing-demands-of-elite-athletes/
  2. https://footnotesblogging.com/2016/01/22/the-d-generation-achillies-tendinopathy-on-a-continuum/

 

  1. Running is bad for your knees
    Any activity performed with poor biomechanics or technique will increase loading of the body’s tissues and increase risk for injury. The loading of unprepared tissues will
    cause injury to the region or affiliated region of those tissues. Repetitive loading associated with endurance sport can be detrimental to the joints if they are not adequately prepared for the activities they undergo. So is knee injury in runners associated with running itself or an inability to complete the strength work required to best prepare the body?
    https://footnotesblogging.com/2017/01/29/strength-training-in-long-distance-runners/
  2. https://footnotesblogging.com/2017/02/28/prevention-vs-performance-managing-demands-of-elite-athletes/

 

 Runners do not need to strength train

  1. Strength is the underlying principle for endurance. Muscle endurance is the tissues ability to complete repetitive contractions over a long periomidfoot striked of time. The ability for an individual to complete their chosen endurance running distance is reliant on the strength of the tissue and the ability to handle the forces being placed through them.
    https://footnotesblogging.com/2017/01/29/strength-training-in-long-distance-runners/

 
Just because an Ivy League university has published a paper which has been lucky enough to have one of its sentences from the abstract quoted in a health magazine does not necessarily make it correct. The context of that quote is one point to look at but also the quality of the study which was completed and what the five studies before it with similar methods concluded. If one study states strong black coffee is good managing anxiety but all the research papers before it states the opposite, which will would you follow?

Until Next Time

 

Jackson McCosker
Director/ Chief Editor

From The King’s Kicks to Scientific Sports Shoes: The History of Football Boots


King Henry VIII is the owner of the earliest pair of football boots on record, although the game had been played for hundreds of years before his reign. His custom made football boots were developed by his shoe maker; they were ankle high and had as many as 6 leather studs attached to them. Changes to these designs were few and far between over
the next three hundred years or so as people began to modify their steal cap work boots by hammering metal studs and tacks into the sole of their shoes. However, as new lawsshutterstock_140849947 were brought to the game of football so to was regulation of the equipment and footwear. In the 1800’s the requirement for rounded studs was introduced and the low cut shoe began to make an appearance – at this stage many of the boots were made from a strong and heavy leather with each shoe weighing as much as 500g, in some cases their weight would double when they became wet.

From 1900 to 1940 there was very little change in football boots due to both World War I and World War II, however during this time and soon after came the development of commercial boot manufactures ADIDAS and PUMA. With these businesses now beginning to mass produce sporting footwear there was a motion away from a purely protective shoe to a light, flexible and synthetic material allowing for better ball control and athletic prowess.
Throughout the 1960 – 1980 era commercial air travel became more affordable and safe, leading to an influx of international matches outside of the FIFA World Cup for lovers of sport to see live or televised. Of course this allowed for those manufacturers to build their brand and sponsor elite athletes of local and international origins.
In the 1980’s came the rise of sport science and with it a change in football boot creation as discussion began about optimal placement of cleats, their shape, their composition and how many there should be on the sole of the shoe.  Additionally, what materials should be used within the shoe, the use of different textures to increase control and manipulation of the ball and most recently the introduction of 3D printing have all contributed to the current football boots available on the market.

So what does the current evidence say about football boots and injury risk?

Much of the newer research which I was able to find has begun to defer from the football boot itself and focus on how the extrinsic influences such as surface (synthetic turf, various grass and court) interact with the boot and contribute to player risk. Similarly, evidence also investigated how balance and proprioception was effected by football boots. These topics are of importance due to the prevalence of noncontact injuries as a result of pivotal movements or direction change such as ankle inversion sprains and ACL injury in football.

Further information on those injuries can be found here:

ACL Injury
https://footnotesblogging.com/2017/02/03/acl-injury-no-longer-the-end-of-a-career/

Inversion Ankle Injury
https://footnotesblogging.com/2014/06/11/ankle-sprains-lateral-ligaments-instability-and-rehabilitation/

The humble football boot has come a long way over the last 200 years from a simple clog with nails through the sole to a piece of scientific art sold on theory and colour to people who participate in all forms of the game. Although, soccer may be considered “The World Game”, football boots have adapted to many sports who tout themselves as being the “true football”. In Australia we fight between Aussie Rules, Rugby League, Rugby Union and Soccer. In America its Gridiron and Soccer. However, although these games are very different in rules, player builds and regulation, many of the movement patterns required of the athlete are similar and therefore the commercialisation of these products is possible to cover all bases.
I hope you enjoyed this short overview.

Until Next Time

Jackson McCosker
Director/ Chief Director

 

References

Brock, E. (2012). Biomechanical Differences in Two Common Football Movement Tasks in Studded and Non-Studded Shoe Conditions on Infilled Synthetic Truf.

Iacovelli, J. (2011). Effect of Field Condition and Shoe Type on Lower Extremity Injuries in American Football. 1 -86.

Notarnicola, A., Maccagnano, G., Pesce, V., Tafuri, S., Mercadante, M., Fiore, A., & Moretti, B. (2015). Effect of Different Types of Shoes on Balance Among Soccer Players. Muscles, Ligaments and Tendons Journals, 208 – 213.

Page, M. (2013). Plantar Pressure Measures of Running and Cutting Movements on Third Generation Artificial Turf and Natural Grass.

Waddington, G., & Adams, R. (2003). Football Boot Insoles and Sensitivity to Extent of Ankle Inversion Movement. British Journal of Sports Medicine, 170 – 175.

Wannop, J., Luo, G., & Stefanyshyn, D. (2013). Footwear Traction and Lower Extremity Noncontact Injury. Medicine & Science in Sports & Exercise, 2137 – 2143.

 

Casting A New Light On Orthotic Prescription and Manufacturing with Neil Smith


 

vfas2Professional Achievements
Winning on the New Inventors
Getting the VFAS into Temple University Podiatric Hospital where 2 years of research have just been completed.
Presenting the VFAS at The Biomechanics Summer School in Manchester with Dr Simon Spooner
Presenting the VFAS at the PFA in Boston
Being interviewed on 2GB by Dr. Graham on the VFA

 

In 2007 you won the New Inventor Awards as part of the popular ABC television program with your presentation of your Vertical Foot Alignment System. In the ten years since how has your perception related to orthotics and orthotic prescription changed?

My perception hasn’t changed about correcting the foot’s alignment with the VFAS since the New Inventors…and can’t believe it’s been ten years! My perceptions have changed regarding, forces, loads, ZOOS (Zones Of Optimum Stress, a term coined by Dr. Simon Spooner), Supination Resistance and how they effect the orthotic prescription, irrespective of the technique you use to capture the foots shape. If you apply the right amount of force to damaged tissue and offload those damaging forces…job done! I guess that’s why OTC’s are so popular. If it works and you put the tissues in their ZOOS, all good!

The Vertical Foot Alignment System is a unique way of casting clients; why do you believe it is so important to cast people weight-bearing?

There are so many ways to capture the foots shape for a custom orthotic: Non-WB (using plaster bandage for suspension, supine, prone, 4th and 5th loading…), Semi-WB, WB (uncorrected), Foam Boxes (MASS, Semi-WB and WB), laser scanning which is accurate to a thousands of a millimeter! Scan with an I-Pad or mobile phone and send the image to get a 3D printed orthotic and there’s also Amfit and Orthema (and others) which have the pins that come up to meet the foot and fabricate orthotics from that profile…the list is endless.

The one thing they have in common…they are all modified! Some less than others, but
still modified, so the orthoses applies forces to the plantar foot to offload the damaging forces. By aligning the feet WB on the VFAS, the practitioner has total control over the forces applied to the Rear, Mid, and F/F on the Lateral and Medial sides. It captures the elongation of the foot, fatty tissue spreading, bony prominences and how much mobility the foot has, so you can only do to the foot, what the foot is capable of doing. What I mean by this, is if the foot doesn’t have the ROM, for whatever reason, you’ll see and feel this when you’re taking the mould. You can’t put a round peg in a square hole!

There’s a tipping point for all feet and if you go past this point the foot will slide off the orthotic. If you try and make the foot do something it can’t do because the corrections you choose are trying to force the foot into a position it’s not capable of getting to, it will either feel really uncomfortable or the foot will just slide off because of that tipping point, which can be uncomfortable anyway. When you align the feet WB you can see that tipping point and balance those forces out between the Rear, Mid and F/F, which have a real Kinematic effect on the feet, ankles, knees and hips, into the back. When you stand on an orthoses made from the VFAS, you should feel like you’re foot’s “in it” and not “on it” and feel taller because of the Kinematic change it has on the foots posture.VFAS.jpg

Different practitioners tend to have a stance when it comes to the best kind of footwear to accompany an orthotic. Some prefer a neutral/cushion shoe, while others chose a more controlling option. Where do you stand on the issue?

I always go for the Neutral option when it comes to shoes as long as it’s not too soft. If the orthotic is doing its job and you have a shoe that’s extra firm on the Medial heel and under the MLA, it can over correct and the foot can become laterally unstable. I think at the best of times shoes give most practitioners headaches.

There is a progressive move toward the scanning of feet instead of casting to limit mess and cost to a business. Is the VFAS compatible with these advances in technology? 

There’s no doubt that plaster will be phased out. It does take a great mould of the foot (especially on the VFAS), but it’s too messy and has to go. I’ve been working with low temperature heating thermoplastics for the last couple of years and all of the VFAS moulds will be done this way, hopefully by the end of the year. No mess and the patient will feel what the orthotics is going to feel like straight away. I’m putting a system in place where you can add pre-glued cookies to the Heel, Cuboid, MLA, F/F and Mets so the patient will have something instantly so once you know the shape is right and the patient is happy, just scan the moulds (which I call Foot Aligners), fill the script out on-line and send me the information over the internet to have a direct milled orthoses or positive mould and have it made the traditional way and vacuum form the materials over the positive to be made.

Is the use of the Vertical Foot Alignment System appropriate for all clients? Given the various types of conditions a patient may present with are contraindications for the use of the device. 

There will always be contraindications with any technique you use and it’s no different for the VFAS. Anyone (mainly kids) less than 30 Kg’s is probably too light, people with spasticity or severe balance issues and if your too old and frail. On a whole, it’s pretty rare and the oldest I’ve had on the VFAS is 97, the youngest is 7 and the heaviest was  ~170Kg’s. If I were going to take a cast for an orthoses, I’d use impression foam and use MASS technique (Semi-WB) and slightly modify the severity out of the MLA by modifying it with plaster.