Comments for Lower Extremity Review Magazine

Comment on Charcot-Marie-Tooth patients delay using prescribed ankle foot orthoses by Keith E. Vinnecour, C.P.O. (E)

Keith E. Vinnecour, C.P.O. (E) — Tue, 07 Feb 2012 16:30:19 +0000

I have treated many patients with CMT and found that when the correct AFOs are applied the individuals walked faster and were able to walk longer. Therefore, this information would only be of value if the exact type of AFOs were described. The correct AFO would allow free plantar flexion with a dorsiflexion assist. The correct AFO would have corrective forces on the foot and ankle to force them into a more normal anatomical alignment, which would have the knees track more on the line of progression and the AFOs would have to be rigid enough to maintain these corrective forces. Supinate feet are more difficult to correct then pronated feet, but the supinated feet are more comfortable in the footplate of the AFO then without. You might check out the information from Becker Oregon for more detailed information.

Comment on Out on a limb: Next top model by Robert A. Weil

Robert A. Weil — Tue, 31 Jan 2012 20:44:34 +0000

Hey Jordana- Another great article! NOW – if that “shoe system was “Celtic green! (kidding). Having “moldable inserts”( molded in what position we might ask), & expecting it to do much is guesswork at best. The discussion of high vs. Low tops has been around forever & the “proprioception” factor in high tops is still an important factor. HOWEVER- “the gold program” remains re. PREVENTION of ankle sprains 1. proper custom orthotics. 2. aggressive individual foot, ankle strengthening. 3. Indiv. Decision re. Ankle tape vs. Brace vs. Neither. Hard to argue with Kobe’s greatness but this is mostly “good marketing”, not good biomechanics…. Dr. Bob Weil

Comment on Charcot-Marie-Tooth patients delay using prescribed ankle foot orthoses by Melinda Lang

Melinda Lang — Thu, 26 Jan 2012 21:53:11 +0000

As someone who has CMT, I know this to be true. After being fitted for my first brace, which was quite expensive, it spent more time hiding in the closet then supporting my leg. Then my doctor told me, 2 yrs ago, it’s time to get an AFO for my “good leg.” I’m still waiting for a better type of AFO then what I already have for my weaker leg.

Comment on Preventing wrong-site foot and ankle surgery by Howard

Howard — Tue, 24 Jan 2012 19:55:52 +0000

This is such a great article, I’m so happy information like this is available to the public. Giving potential patients information like this helps us take an active role in insuring safety- verifying the Doctor’s marks and all. Thank you for taking the time to publish this!

Comment on Initiate weightbearing early after hip fracture by Adam

Adam — Fri, 23 Dec 2011 21:54:47 +0000

Excellant Article. I run into Hip ORIF’s being toe touch weight bearing. THe problem is the geriatric population is unable to perform this without weight-bearing. Also, one would think that weight-bearing would promote healing in a bone such as the femur. Thank you for this article.

Comment on Jazz shoes restrict plantar flexion, may also impair muscle activation by Robert Scott Steinberg, DPM

Robert Scott Steinberg, DPM — Tue, 13 Dec 2011 14:39:22 +0000

The dance patients who present to my office mostly have plantar fasciitis, metatarsalgia, Achilles tendonitis, or ankle pain. Most respond well to changing to a shoe that provides some additional stability, and or improve with the addition of prescription foot orthotics . Without a doubt, available motion at some joints are limited (better controlled). But I would never suggest to my patient that there is any sort of negative trade-off, as the choice faced is being able to continue dance or having to quit. The findings of “could” and “may” do not give much value to the results of this study.

Comment on Pretty pathways to pain: Muscle activation in high-heeled shoes by Harvey Johnson C.O.

Harvey Johnson C.O. — Tue, 22 Nov 2011 19:31:51 +0000

The most obvious component missing from this study are the dimensions of the contact surface of the heels. I cannot assess from the pictures nor from the article if the heel dimensions of the low heel and high heel shoe were the same. My best guess is that the contact area on the low heel shoe was much greater than the high heel shoe. If the heel dimensions are indeed different, that would change the outcomes of this study. Maybe the authors could clarify the heel dimensions of the 2 shoes used. I would be interested in outcomes of high heel shoes with heels that have a much larger contact area vs. the extremely narrow heels used in this study.

Comment on Bracing and rotation, part 2: ACL injuries by Robert A. Weil

Robert A. Weil — Tue, 22 Nov 2011 19:04:54 +0000

Hi Cary- EXCELLENT 2 part article, – THX for including my insights. A point I’d like to make however is that my orthotics observations re “all aspects rotational”, SPECIFICALLY ACL problems & injuries is by no means limited to figure skaters with females. Sports like volleyball, soccer, tennis, basketball, ETC, ETC.– most if not all rotational related lower extremity problems (again emphasizing ACL), are helped with the proper CUSTOM orthotic therapy! Keep up the great work, happy turkey day…..Dr. Bob Weil

Comment on Out on a limb: High on heels by Robert A. Weil

Robert A. Weil — Tue, 22 Nov 2011 18:39:10 +0000

Hi Jordana- I always felt that barefoot activities in the sand allowed all sorts of new muscle activation for our feet, ankles, especially intrinsically for the feet- so take advantage! Interesting insight re “subgroups” of women who might have less “problems” re wearing heels. My thinking is that the flexible, even ligamentous lax foot type would tolerate “changes like heels to mechanics” re problems with feet, & areas above, (ala subgroups). Rigid foot structures less tolerant—- anyway, get a good tan!….Happy turkey day.. Dr. Bob Weil

Comment on Roomy Socks by John Hruban

John Hruban — Tue, 15 Nov 2011 15:15:14 +0000

Received socks thru VA. Are great, but they need to reduce the adhesive on the bands as it is very easy to damage the delicate fabric when trying to remove the band. These are not inexpensive so why risk the possibility of damaging them whle tryig to remove the very sticky, adhesive band. Thnak you
John Hruban

Comment on Sanford Health and ACSM establish institute to protect young athletes by Matt Ditmanson

Matt Ditmanson — Tue, 01 Nov 2011 12:54:15 +0000

This is an exciting partnership and opportunity to make a positive impact in safe youth sports participation.

Comment on Out on a limb: Subtle distinctions by Warren Potash

Warren Potash — Sun, 30 Oct 2011 19:49:24 +0000

How true are all statements in “Arming at risk kids.” Next to last paragraph: “Prepare for life after sports…” I have been telling anyone who will listen since 1999 when the OA research showed that 70% of female athletes will have OA whether surgery is required or not in 12 years whereas male athletes may or may not have OA within 20 years.

Since 1995, I have trained >600 teen female athletes with remarkable results. Yet, about 99% of parents/guardians believe something bad will happen to others, not their daughter-athlete. When the youngsters hear their Dad (more so than Moms) say training to play sports is not important then it is not valued. Therefore, one of my main messages is just that: Today, all female athletes need to value training to play sports.

I believe if training is valued then we do not have to talk about the OA and other challenges as much since we know that safe and age-appropriate training for teen female athletes (now researchers want 9-12 year old females to stabilize/strengthen their lower body) will minimize their risk for injury.

I hope future editor comments can be directed towards reminding everyone that now – all females – need to train to play sports.

Comment on Orthotic management of the pes cavus foot by Harvey Johnson C.O.

Harvey Johnson C.O. — Fri, 28 Oct 2011 17:25:54 +0000

As an orthotist for 34 years I have significant clinical experience in treating neurological cavus feet esp CMT. I also have significant experience in foot orthotic management of both the athlete and non-athlete. Although I have evaluated, designed and made my fair share of AFO’s for the neurological patient, my present practice is limited to pedorthotics: all of my technical work is done by me so I also have a great deal of experience in designing, fabricating and fitting foot orthotics. And with a family full of cavus feet I have quite a unique perspective on the “cavus” foot. In random order I will address a few of the issues by the author.
1. Having a high arch does not mean one has a “cavus” foot. Most people I see that have high arches are pronators. In weight bearing the talar head with be palpable on the medial side. This would not be happen in a true cavus foot.
2.. A true cavus foot does not pronate at anytime in stance phase. The medial talar head is never palpable in weight bearing on the cavus foot. Therefore this foot type is by my definition “rigid” and trends towards supination during stance phase. More supination occurs with those with plantar flexed 1st rays and also with those whose lateral heel structure has a decreasing radius on the plantar surface. True cavus feet represent less than 1% of the population I see in my clinic. Some cavus feet have a plantar flexed first ray and others do not. Ex: I have bil plantar flexed first rays yet both my brothers whose alignment is otherwise the same as mine do not have plantar flexed first rays. A cavus foot is not a result of muscle imbalance but a result of boney alignment that is inherited. If the author is correct in the “developmental” cavus foot then my mother, myself, my brothers and their children who all have cavus feet inherited the same muscle imbalance. I find this highly unlikely. More than likely one grows into the boney alignment and develops the associated claw toes and tight achilles as a result of said alignment. I was once very sick and was waiting on an evaluation by a neurologist. I looked at my wife and warned her the neurologist was going to take one look at my feet and ask if I had Charcot Marie Tooth. True to form she did exactly that in less than 5 minutes after meeting me.
2. Plantar flexed first ray’s are not uncommon throughout the general population and they are not limited to just the cavus feet.
3. Jone’s stress reactions/fractures: In addition to my private practice I was also responsible for providing all the orthotics services to a large Div. I school athletics department. I treated scores if not well over a hundred Jone’s fractures. A. I have NEVER seen a Jone’s fracture in a runner. A Jones’s stress fracture is first and foremost a torsional injury. 2. I have kept many of the foot casts (taken in non-weight bearing STJ neutral) on these Jone’s fractures. My vast clinical experience says it is entirely untrue there is a correlation between high arches and Jone’s fractures. In fact I am hard pressed to find high arched foot in the group much less a true rigid cavus foot.
4. Although metatarsalgia is easier to explain in the “tripod” plantar surface of a high arched individual I find it quite common in people with lower arches.
5. Neutral/normal foot: just what is a normal or neutral foot? I hear these terms used interchangeably over and over. Yet I find no consensus definition. I experience a wide variation in foot types that I refuse to use neutral/normal and pathological. I prefer to describe the foot from a functional perspective and with emphasis on comparison between the open and closed chain alignment.
I do not think their is any mystery to the cavus foot. Nor is their any mystery to the high arched foot that pronates:with or without a PF 1st ray. They are what they are. Unless someone has a neurological or traumatic reason for a “true foot pathology” then the foot is just as much an part of our genome as the rest of our body.

Comment on Achilles Contracture Management Orthosis by Donna Rose

Donna Rose — Wed, 19 Oct 2011 13:35:43 +0000

Can any body please advise? I have been using the achilles contracture now for 8wks, every evening for an avg of 1hr 30. I am starting to notice that the following day my knees and thighs constantly ache until I sit down. Is this a normal feeling or am I doing the exercise wrong?

Comment on Preoperative exercise boosts TKA outcomes by Swearingen

Swearingen — Mon, 17 Oct 2011 07:14:38 +0000

I had a patellofemoral replacement 3 years ago and went through a 3 month pre-rehab. While some of the exercises were too difficult, working with a therapist we were able to modify and still get the desired effect. I am currently in nursing school and my remaining knee is ready for a full replacement. I will be going through another round of prerehab for this next knee – it is so worth it. As a ortho patient past and present and an upcoming ortho nurse, prerehab is the way to go!

Comment on Kiddythotics in Seven Sizes by Ike Broach, CPed

Ike Broach, CPed — Wed, 12 Oct 2011 20:45:38 +0000

I would like to obtain one of your Sizer Sets for kids. Please send me the info/cost etc.

Comment on Genium Prosthetic Knee by CJ Yerry

CJ Yerry — Wed, 12 Oct 2011 05:43:21 +0000

I have one of the remaining original X2 prototypes back again after a second world tour back home to Otto-Bock, fixed, and then back to me and have loved it since the day I put it on a few years ago. Is this the mainstream commercial version of it and if so, were there any modification we asked for put into this version? Is this going to be the new equivalent of the C-Leg and get mass fitted onto future military amputtees coming through the new Besthesda/Walter Reed prosthetics department now? Just wondering when to go start asking them.

Comment on Momentous adaptations: Offloading the knee through gait modification by Joaquin Barrios

Joaquin Barrios — Thu, 06 Oct 2011 14:55:49 +0000

Al,

It is important to recognize that individual patterns cannot necessarily be combined. Frankly, we don’t know much about combining patterns to date. If you are interested in implementing a pattern, choose one. As we study more about pattern modification, we will be able to provide more robust recommendations.

As far as your comment on trunk lean goes, the mechanical effectiveness has more to do with the altering of the direction of the GRF vector, as opposed to the COP under the foot!

Comment on Pros, cons of pressure in foot orthosis design by Jeryl G. Fullen, M.D.

Jeryl G. Fullen, M.D. — Thu, 06 Oct 2011 01:45:34 +0000

We have been measuring in-shoe plantar pressures during gait for over 10 years based on US Patents of our technology of resistive ink sensor matrix arrays designed specifically to conform to a changing compound surface (the inside of the shoe). Each sensor in the array is calibrated from 1-144 psi and a matrix of correcting values established for each active sensor. This is done in-house before shipment. Other measures are utilized to further minimize the effects of hysteresis. Our gait force analysis application calculates Shear gradients by region and globally and organizes vast amounts of data in an orderly fashion to be quickly utilized in a busy clinical or research setting. Sequential measurements allow monitoring the effect of pressure redistributing orthotics and footwear on shear gradients in the clinical setting. We have a US Patent on a direct pressure redistributing foot orthosis which is milled based on data collection during gait. We are FDA compliant and the foot orthosis is approved under the CMS Medicare TSB A-5513 custom foot orthosis.
This system is simply a very handy tool. It, however, must be used in conjunction with one’s clinical experience and judgement. I cannot tell what a person’s blood pressure is by just looking at an individual – I have to take a blood pressure measurement or even a series of blood pressures to get a more accurate assessment. So it is with gait force analysis. As time goes by and more sophisticated applications are available, compensatory off loading from high pressure painful areas can be sorted out so that more accurate foot orthotics can be produced. The neat thing is that any orthosis can be rechecked during gait with the same sensor array to confirm outcome. Patients with diabetes and small fiber neuropathy involvement of their feet with loss of protective sensation probably do not get compensatory change in loaded gait. This is where ongoing gaited gradient shear assessement of the entire plantar foot is more critical. Once a foot orthosis is fabricated or adjusted, a post fit gait analysis must always be done within 1-7 days of wear and adjustments made as required.

One final point: CMS TSB reimbursement is not based on outcomes (progressively lower gradient shear). This one issue must be addressed in order to expect the diabetic neuropathic foot re-ulceration rate to drop. Once this issue is addressed, reimbursement for this professional activity should be approprately compensated. Preventing an ulcer, infection, amputation, and even death should have a significant reimbursement value. But today our federal reimbursement policy discourages innovation because collectively we do NOT have a compelling story to tell. Since the advent of the TSB coverage May 1993, the re-ulceration rate in the best reported peer reviewed literature has stayed about the same (22% over 2 years). The technology is here and there is no reason we should not collectively get our act together to make a difference to get the outcomes our diabetic foot patients deserve. Only then will we have a compelling story to tell.

Comment on Beyond Bunionectomy: The Role of Physical Therapy by Dee Tezelli

Dee Tezelli — Tue, 04 Oct 2011 16:25:14 +0000

Had bunionectomy 7/25th. I’ve been doing knee/ankle self PT at home almost immediately after.
Went back to work 9/15th. Feel good enough to start my usual hiking/running but, can’t get
my foot into the footwear. Swelling only on top of foot and slight stiffness in th big toe is the
problem still in 70th day. Starting to concentrate on big toe in/and/out PT to expedite healing.
Any other quick fix ideas to fit into my shoes? Thanks.Dee in Seattle .