Signs of gait improvement with foot orthotics

ZOOS?

 

An acronym for Zone of optimal Stress. (Spooners ZOOS) See 'New goals Podiatric biomechanics' thread.
Will become a euphemism or metaphor (depending on your view) for biomechanical intervention based on individual solutions for individuals. Where clinicians use their skill and knowledge to formulate a treatment (which may be an othosis) which is not based in demographics or dogma.

Sincerely Dave

 

Why would you think that her medial knee pain is caused by iliotibial band or gluteus medius problems?

Thank you, Dave, for providing us with a great example of why every podiatrist should know how to do a good visual gait examination. As one gets better at visual gait examination, even the more subtle changes in gait are quite obvious. And how much did it cost the patient for you to "record" this change in gait? How long did it take you to "record" this change in gait? How much equipment did you need to "record" this change in gait? The cost and time benefits of visual gait analysis are very obvious once you start doing a time/cost analysis of visual gait analysis versus other methods of recording the kinematics of gait in a busy clinical practice.

Why would you want to only achieve symptom reduction when you could also possibly prevent problems in the future for your patient? Should we, as health care providers, only treat the current symptoms or as you say "just enough to relieve foot pain is all that is required"? Or should we try to not only provide symptom relief for our patients but also try to optimize the gait of our patients also?

Does an internist prescribe anti-hypertensive medications for current symptoms? No, he prescribes them to try and prevent cardiovascular accidents in the patient's future life. In the same way, ideally, one should be trying to optimize the gait for the patient, when possible, as long as this gait change does not cause new symptoms to arise.

If a 5 year old child has a severely pronated foot but currently has no symptoms, should we not treat them because they are asymptomatic, even though their parents have a history of severe foot pronation that caused severe pain and disability in their adolescence and adulthood? Should the patient with multiple sclerosis that walks with a 20" base of gait and complains of an inablility to walk for long distances, but has no pain associated with gait, not be treated with in-shoe inserts to try to improve their gait stability? Certainly, I would think that the healthcare professional that is striving to do the most for their patients would want to offer much more to their patients than just "symptom relief". This is especially true since we may often be the only healthcare providers the patient may see that actually has the ability to diagnose and treat these gait disorders.

A normal 80 year old does not ambulate like a normal 20 year old so we should not try to make the 80 year old walk like a 20 year old. However, I agree that the older the individual, there is less of a reason to want to optimize gait since this gait change may not be tolerated as well as in a younger individual and they are just wanting to live out their last few years of life being "comfortable". However, would you use the same logic in a 30 year old with posterior tibial tendinitis? Would you prefer to be the patient of the podiatrist that is only out to make your pain better, or would you rather prefer to be the patient of the podiatrist that is out to not only make your pain better but to also prevent pathology for you in your future life?? I know which podiatrist I would choose as my healthcare provider!!

Was it dogmatic of you, Dave, when you noted that your patient's "gait became almost symmetrical with a fairly normal swing and stance phase bilaterally and the Q angle became much more shallow". How did you know that her gait kinematics had improved unless you had some "dogmatic expectations" of what normal gait should be for your patient? Was it because of "dogmatic expectations" or perhaps, because you had been taught that "symmetrical gait", "normal swing and stance phase" and "Q angle was more shallow" was a more "normal" gait pattern for this patient.

I refuse to believe that we, as podiatrists, don't have enough knowledge regarding what normal gait kinematics should be in the human population that we shouldn't attempt to offer optimized gait patterns to our patients as one of the therapeutic benefits of custom foot orthosis therapy, shoe therapy, and stretching and stengthening therapies. As far as I'm concerned, if you, as a podiatrist, are only out the "make symptoms better" with orthoses, then you are not offering full service podiatric biomechanics treatment to your patients.

 

Hi Dave and Kevin

Thank you for your replies. I thought Daves explanation and example of a VGA was excellent and serves to show that VGA can be done with practice and bring benefit as well as personal satisfaction.

If we accept that foot function affects upper body actions and vice a versa then I believe (hint of dogma here!!!) we have to employ and develop increasing VGA skills. This is particularly the case when working along people such as physios who may want you to, at least consider, if a podiatric intervention (e.g. orthosis) could help bring better upper body function.

Over my own years of working with them it has become possible to actually seriously consider this because of observing changes resulting from lower limb intervention.

I can understand Daves comment about optimising the gait of an elderly person. However, the issue may not always be one of optimising (and I do like simon's ZOOs as it describes the approach I have taken for the last ten years) For some of the elderly I have treated even a marginal alteration to whole body action has been very welcomed and beneficial. It has been working in this kind of wholistic context that has partly shaped the way I work and think. It also underlies the way I have taught people to view podiatric biomechanics and assess people.

Ian

 

Kevin

OOps sorry that should be 'lateral knee and hip pain'

Cheers Dave

 

David:

Thanks for that clarification. I hope you didn't feel I was picking on you with my last posting but I feel I needed to make a point....using your posting as the resource.

I gave this some thought during my run this morning since I was feeling somewhat badly that I suggested that podiatrists that have a goal to just make someone asymptomatic were simply not doing enough.

Optimizing gait is a much more difficult thing to do with foot orthoses than getting rid of symptoms. This requires that the podiatrist reasonably assess how much they can "push" the patient's foot and lower extremity with an orthosis to make them have improved gait, without "pushing" them so hard that other symptoms occur. The potential to achieve more optimal gait kinematics will be dependent on the patient's age, strength, flexibility, characteristic structural makeup and functional capacity of their neuromuscular system.

Even though my first goal with foot orthoses is always is to relieve any painful symptoms, my second goal is to see if I can squeeze out a little more correction of the patient's gait by using strengthening or stretching exercises, or using different shoes or orthosis corrections so that my patients may walk with a less pathologic gait pattern. In this way, I feel as if I am providing my patients with a much more valuable medical service than just making their symptoms better for the short term.

I hope this clarifies my last posting since I feel very strongly about podiatrists needing to learn how to do proper visual gait examinations and not just stopping short of making the patient's symptoms better when making foot orthoses for them.

 

Kevin

I usually make an in depth Visual assessment of the whole body in gait and stance before prescribing and manufacturing orthoses. It can be very useful especially when things don't go to plan initially. The initial assessment takes about an hour including foot scans, podotrack prints and recording on the database. Noting changes takes little time but would not be possible without records as I don't have total recall. Costs break down roughly as £35 for assessment, £100 for orthoses, £80 for fitting and follow up.

I know very well the cost and time involved in doing a full comparative kinematic study of a persons gait. Man hours and equipment costs would run into many thousands of pounds.

To answer all three points at once.

To quote myself I did say "I think that making gross changes in the gait pattern when there is no pathology, in terms of pain, in proximal structures may be unwarranted." sometimes it may not.


Can I be sure that 'improving' the gait style will give more positive outcomes in the long term? Can I be sure that changing the gait style to be closer to the gold standard will not result in increased proximal pathology in the short or long term. I think this is a judgment call for the clinician to make in each individual case. Perhaps this could be called a risk assessment, does the expected gain outweigh the potential risk. All medicine has this dilema I believe and all treatment has some risk.

I think my main point still stands though Kevin. If I want to attain a certain style of gait I can but I am not obliged to do so. I can resolve the patient's pain without tearing my hair out because I didn't attain a perfect gait for this patient.

Kevin Imagine you had a patient to whom you had fitted temp orthoses with only small medial posts and their symptoms had completely resolved after a couple of weeks. Would you then look at their gait and then say oh we need 8 more degrees of medial posting to achieve the 'perfect' gait. Then make your orthoses accordingly. I don't think I would.
However if the goal was to resore the gait of the five year old with familial history of pathology related to poor gait then it may be entirely appropriate to do this.

No it was not. I did not apply a dogmatic solution that obliges me to return the gait to a pre determined standard position in the hope that it would relieve symptoms. Instead I applied logical thinking which indicated that I return the gait to a style that would give minimal external moments applied by GRF and therefore minimal internal forces required to stabilise the joints. I designed my orthoses accordingly. The actions and outcome may, in this case, be the same but the thinking is different.
Unfortunately I must use standardised, mainly qualititive, terms to record and communicate my observations, which gives the misleading impression that I use a standardised approach. If I were to use a quantitive form of data collection and recording then there would be the aforementioned prohibitive costs. However there would clearly be no predetermined solution to the problem of reducing external moments about the joints of interest.

Therefore Kevin, I would conclude that even though we appear to differ our views are are not mutually exclusive and are, on the contrary, the same technique of using principles of physics of mechanics to best treat our patients. Isn't this the principle of SALRE and Tissue Stress (modified as ZOOS) applied to the whole kinetic chain.

Here is another practical example which demonstrates this principle of ZOOS.

Lady 70yrs, presents with bilateral numbness and ridged callus on the medial foot. She has no vascular or neurological disorders.
Biomechanically she has an extremely translated STJ axis so that she is compelled to stand on the medial side of her feet but there is little pronation or flattening of the MLA. No proximal pain. In gait the lateral edge of the feet barely touch the ground and the pressure mat (podotrack) shows very low peak plantar pressure here.

Dogmatic solutions.
1) Return to neutral position in stance ie 3 dgs inverted. make orthoses that invert the foot.
2)Cast in MASS position, feet and gait will be returned to normal.

My solution full length valgus post. This will move CoP laterally and reduce plantar pressure on the medial foot. Reducing medial pressure may also allow windlass system to operate and foot funtion and perhaps more proximal function will improve.

I did not think that this lady would tolerate any effort to supinate the foot with orthoses given the position of the STJ axis gave no moment arm for potential supination forces.

The lady felt the feet were more comfortable with the temp orthoses. Review not for 1 month yet so we will see how thet treatment works.

On the contrary Kevin, it is precisley because we do potentially have sufficient knowledge to not use dogmatic paradigms that we can offer a full and holistic service to our customers.



Respectfully Dave

 

Kevin

quote
"I hope you didn't feel I was picking on you with my last posting"

No certainly not! I enjoy validating my opinions. If I can't then I need to rethink. Its all a learning experience.

Cheers Dave

 

Excellent and well-thought out reply, Dave. I don't think we are too far off in the way we approach things clinically.

However, you must remember that just because a STJ axis is medially deviated and the CoP is moved from far lateral to the axis to a position less lateral to the axis, the STJ pronation moments will still be reduced by the change in CoP. In other words, to get a "supination effect" from a foot orthosis, all one has to do is shift the CoP more medial....the CoP does not need to cross the "magic line" of the STJ axis toward the medial side of the STJ axis to get a STJ supination effect (i.e. either increased magnitude of STJ supination moment or decreased magnitude of STJ pronation moment).