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orthotics: when self-help and sports therapies don’t go far enough
In the last issue, I looked at the basic anatomical and biomechanical dysfunctions that often lead to overuse injuries in the joints and specifically at the role of faulty foot mechanics (PP 205, November 2004). The current article goes on to consider a range of treatment regimes for chronic sports injuries, including orthotic therapy and prevention. The focus here is on chronic, recurrent injuries that are a result of repetitive micro-traumatic overuse syndromes, including shin splints, foot arch pain, runner’s knee, jumpers knee, ilio-tibial band syndrome, sacro-iliac joint dysfunctions, and chronic low back pain. Such overuse injuries are commonly caused by underlying biomechanical weaknesses in the involved joints. These weaknesses, in turn, can be caused by such previous severe macro-trauma as fractures or severe ligament sprains. However, the emphasis here is on the biomechanical role of the foot in absorbing shock at impact, and facilitating propulsion at push-off during the gait cycle.

As pointed out in my previous article, the normal foot pronates (rolls inwards) and supinates (rolls outwards) while it is moving from heel strike to toe-off. When normal pronation and supination become excessive due to abnormal structure and function in the arches of the foot, excessive torsional (twisting) forces result in overuse and irritation to the soft tissues which support the joints in the foot, knee, hip, pelvis, and spine. This is frequently the underlying cause of chronic musculoskeletal conditions in athletes. {Images – Lower Extremity Torsion and Pelvic/Lumbar Torsion and tilt}
 

Although orthotic therapy (use of shoe inserts) can often be a useful tool in the management of these common overuse sports injuries, it is prudent and reasonable to try standard treatments first. Self-directed treatment included the following: • Rest. For most competitive athletes, this is the one word they don’t want to hear. However, a sports therapist should be able to help in designing a cross-training programme that will maintain cardiovascular/muscular strength and endurance while resting a specific injury. A good programme of this type will incorporate strength, anaerobic and aerobic training, using equipment and exercise protocols that potect the injured area by avoiding weight-bearing exercise for a brief healing period. In some cases, rest is required to enable the damaged tissue to repair itself optimally with minimal scarring. Sometimes you simply cannot train or play through the pain without consequences that far outweigh the benefits of continued training or competition. The athlete, coach and sports therapist should work as a team to decide the best way forward for the athlete. • Ice. Applying ice to an injury [cryotherapy] is a common way to reduce inflammation arising from the overuse and irritation of soft tissues. Ice can be applied either in crushed form, wrapped in a moist towel, or as small paper cups of frozen water massaged in to the affected part. Ice treatment is a short term anti-inflammatory treatment, which must be repeated every 2-3 hours for 10-15 minutes to any injury showing signs of active inflammation (determined by swelling, redness or increased skin temperature). • Contrast therapy. This involves alternation of ice and heat treatment. Typically, an athlete applies ice to the injured area for 10-15 minutes, then moist heat for a further 10-15 minutes, repeating the cycle 3-4 times. The ice leads to vasoconstriction (blood vessel contraction) to literally squeeze out any inflammation, while the heat expands the blood vessels (vasodilation), thereby boosting blood flow and supplying oxygen and nutrients to help tissues heal. • Massage and stretching. In some cases, athletes can benefit from self-massage and gentle, painless stretching of injured areas. However, this may require some input from a qualified practitioner. Sports therapists may use any combination of the following treatments: • Ultrasound, which reduces inflammation and stimulates blood flow; • specific massage techniques, such as transverse friction or lymphatic drainage, and sports massage to reduce pain and spasm; • The use of various types of electrical current to reduce pain and inflammation, and boost metabolism; • Mobilisation and/or manipulation of the involved joints (1). With any of these techniques, it is important to make sure that the practitioner is well qualified, with extensive experience of the recommended therapy, before embarking on a treatment programme.

With a first episode of an injury, self-treatment often resolves the problem. If it does not resolve within about a week, it is appropriate to consult a qualified sports therapist and consider further treatment options, which should resolve the condition.

If the problem persists, or resolves then recurs, there is good reason to consider possibility of an underlying biomechanical fault in the foot, which may require orthotic treatment. If your sports therapist does not have extensive experience in this field, you should seek out a specialist in sports orthotic therapy and ask the two to co-manage your case.

Orthotic therapy is used by practitioners of several different disciplines – including podiatrists, chiropractors, physiotherapists, osteopaths and sports therapists – using a wide variety of diagnostic and prescriptive systems. In addition, there are a wide range of materials from which orthotics can be manufactured. Any orthotic therapy is only as good as the quality of the materials and the training and expertise of the therapist. It is therefore a good idea to do a bit of local homework to establish who is likely to provide the highest quality of care, using the best materials.

A qualified practitioner will work in a practice that has a history of providing quality care, including regular use of orthotic therapy, to local sportsmen and women. Be sure to check out the experience and specialized training of your chosen therapist before becoming his or her patient.

In choosing the right form of orthotic device, there are several factors to be considered. Such devices are generally classified as soft, rigid, or semi flexible (2). If, as is possible, you buy orthotics ‘off the peg’, the left and right inserts will be identical. However, in many chronic joint conditions it is asymmetry in the biomechanical function of the feet that causes the abnormal stresses and leads to joint dysfunction and pain.

Soft orthotics are made of varying densities of foam and are prescribed with varying degrees of sophistication. One way is simply to measure the length and width of the patient’s foot for the provision of a generic arch support. Alternatively, the therapist may use a plaster cast or foam impression to create a mould of the foot, which is then used to create orthotics with matching contours. Some practitioners also use videotape analysis of the gait, or a pressure plate to analyse the motion of the foot.

Soft orthotics have the advantages of being relatively inexpensive, absorbing shock well and supporting the medial longitudinal arch of the foot. They may also be able to control the motion of the rear and forefoot, depending on the experience and training of the prescribing practitioner. The disadvantage of this type of orthotic is that they are not very durable, while some of the materials used will compress without rebounding, which minimises their effectiveness over time.

Finally, many athletes find that this type of orthotic will only fit into their trainers! This is a very important drawback because biomechanical foot faults are present all day, every day, with every step taken, and orthotics need to be used with ‘street shoes’ as well as sports footwear.

Rigid orthotics are made with various types of polymer plastics. This type of orthotic can be prescribed using an ‘off-the-peg’ orthotic shell, with a generic arch contour. The orthotic can then be tailored to the athlete’s specific needs using ‘snap-on” or glue-on postings under the rear and forefoot.

Rigid orthotics can also be prescribed using the plaster casts or foam impressions of the feet. In this case, the impressions of the feet are sent to a laboratory where specific measurements are used to modify the orthotics using postings to support the rear and forefoot. Practitioners may also use videotape analysis and/or pressure plate analysis to further refine their prescriptions.

The advantage of a rigid orthotic is that it is quite durable and will last a long time. If the foot requires rigid support to optimise foot function, it is a good choice. The disadvantage is the rigid nature of the plastics used. The anatomical and biomechanical design of the joints of the foot facilitate a high degree of mobility, with pronation and supination being part of normal foot mechanics. Therefore, placing a rigid device within a system designed for mobility is counter-intuitive. There are clinical situations where a rigid orthotic device may be indicated, but this, in my professional opinion, is the exception rather than the rule.

Semi-flexible orthotics are something of a hybrid, manufactured from a memory thermoplast plastic that will accommodate the normal pronation movement of the foot, limit excessive motion and then rebound to its original shape as the foot re-supinates. This rebound effect also allows for proprioceptive feed back within the nervous system as the joints and soft tissues respond to the stimulation of the mechano-receptors in the feet.

Proprioception is, of course, an extensive topic in its own right, but is worth mentioning here as recent research indicates that proprioceptive feed back from the feet is integral to a variety of neuromuscular systems in the body.

Semi-flexible orthotics have the advantage of being both flexible and resilient. They can be prescribed using plaster casts or foam impressions, and practitioners may also use videotape or pressure plate analysis. The fore and rear foot corrective postings are normally applied by the laboratory at the time of manufacture based on the prescription, but subsequent modifications can be made by the practitioner. {Image – Orthotic}

Having looked at therapies in general, we can now go on to consider their role in the treatment and prevention of specific common sports injuries. In any overuse condition, the nature of the injury, tissue damage and treatment protocol are very similar, although specific considerations apply.
 

Plantar fasciitis (PF): foot arch pain {Image –Plantar Fasciitis}

This condition is very common and very easy to treat when identified early, but very difficult to treat once there have been multiple episodes over a long period time, or the condition has become chronic. Useful treatments include: rest; ice massage; self massage; transverse friction massage (applying pressure across a tendon or muscle, rather than along its lenght); ultrasound; interferential current (high frequency electrical input to the tissues to decrease pain and improve metabolism); specific stretching exercises for the foot and calf; night splints to encourage flexibility; and orthotics. In my experience as a practitioner over the last 20 years, I have noted that most cases of plantar fasciitis, especially if identified early, will respond readily to the use of an ‘off the peg’ arch support which can be purchased from a local sports shop or chemist. If the condition persists, a more sophisticated orthotic device may be required.

Medial tibial stress syndrome (shin splints)

‘Shin spints’ is a generic term for any pain in the shin. This, too, is a very common problem and also relatively easy to treat if managed properly. This is one condition for which short term rest is essential, and a combination of relative rest, self treatment and professional advice will frequently resolve it. Useful treatments include ice massage, compression wrapping or elastic taping around the calf, transverse friction massage, ultrasound and orthotics. However, there is a tendency for shin splints to become chronic and recur, and in such cases there is an additional risk of stress fracture. If, on palpation along the medial tibial bone, a small area the size of a fingertip can be identified that is exquisitely painful by comparison with the rest of the shin, this suggests that a stress fracture may be developing, requiring professional diagnosis and treatment.

Patello-femoral tracking syndrome (runner’s knee)

In treating patients with patello-femoral tracking syndrome, my clinical experience tells me that while self treatment may alleviate symptoms in the short term, it is unlikely to resolve the condition without additional sports therapy. In addition, there are a variety of useful rehabilitation techniques that can be brought into play, using specific strengthening and stretching exercises to help balance the quadriceps and hamstring muscles, so to minimising abnormal stresses on the patella (3). There are also mobilisation and manipulation techniques specifically geared to this condition that can be applied by a qualified therapist. However, the underlying mechanism predisposing an athlete to this problem often turns out to be over-pronation of the foot, causing torsional forces in the knee that change the tracking of the patella in the femoral groove, leading to irritation and inflammation. Therefore, in my experience, athletes with runner’s knee benefit substantially from orthotic therapy. A simple arch support as described above is usually inadequate, and athletes are advised to seek a more sophisticated device from a qualitfied practitioner.

Iliotibial band syndrome (ITBS, or lateral knee tendinitis)

This problem is also often caused by biomechanical foot faults – in this case either over-pronation or over-supination. With the former, the torsional forces at the knee over-stretch the tendon on the iliotibial band, resulting in tendinitis tendonosis (an acute or chronic inflammation of the tendon) With over-supination, however, compressive forces in the lateral knee result in irritation to the lateral soft tissues of the knee, including the iliotibial band. In order to accurately diagnose and treat this condition, it is important to take a very careful history, supported by a physical examination (4) Regardless of the biomechanical cause, ITBS can be successfully managed by therapeutic treatment, although orthotic therapy is often of great value. But since orthotic therapy for over-supination is quite different from what is used to treat over-pronation, more sophisticated devices and precise prescription are required.

Sacroiliac joint syndrome (sacroiliitis or sciatica)

Contrast therapy, clinical treatments and manipulation are often helpful in resolving this condition, although chronic joint dysfunction is common and is often related to faulty joint mechanics. The sacroiliac joint is a large and complex joint that links the spine and the leg (5). Therefore, biomechanical dysfunction in any joint in the leg can impact on the function of this joint. It is quite common for athletes to develop a recurrence of this problem following treatment, suggesting that the site of chronic pain (ie the sacroiliac joint) is not the source of the pain. If a practitioner can link the problem to a biomechanical fault in the foot and design a sophisticated orthotic device to correct it, the condition is much more likely to be corrected permanently. Note, though, that it is critically important to include manipulation for joints that are fixated (application of a high velocity, low amplitude, trust into the joint to increase mobility) and stabilisation exercises for joints that are hyper-mobile.

Lumbar facet syndrome (low back pain)

Low back pain is one of the most common ailments known to humankind, including athletes. Contrast therapy, clinical treatments and manipulation are often helpful in resolving this condition. However, chronic joint dysfunction is common and often related to faulty joint mechanics. (6) Lumbar support belts can be helpful when the pain is very severe with movement, but once the acute stage has passed, core stabilisation and rehabilitation are critical. I have worked with a number of athletes who have spent many hours – and lots of money – trying to achieve optimal core stabilisation of the deep muscles of the lumbar spine. However, although a detailed regimen of core stabilisation and proprioceptive retraining of the muscles of the low back is often useful, I tend to find that, when the athlete returns to 100% activity and/or discontinues the rehab, their pain and dysfunction eventually returns. Again, when self treatment, prescribed therapy and rehabilitation fail to resolve low back pain for more than a few weeks at a time, the underlying biomechanical weaknesses must be addressed, and orthotic therapy considered as an option. 
 

-Cherye Roche

{Image – Comparison of over pronated and normal digital scan}



REFERENCES 

  1. Souza, T (2001) Differential Diagnosis and Management for the Chiropractor, 2nd edition, Aspen Publishers, Maryland, USA 
  2. Michaud, T (1997) Foot orthoses and Other Forms of Conservative Foot Care, 1st edition, self published, Massachusetts, USA 
  3. Cailliet, R (1987) Knee pain and disability, 2nd, F.A. Davis Company, USA 
  4. Mellion, M (1999) Sports Medicine Secrets, 2nd edition, Hanley & Belfus, Inc., Philadelphia, PA, USA 
  5. Schamberger, W (2002) The Malalignment Syndrome: Implications for Medicine and Sport, 1st edition, Elsevier Science Limited, London, UK
  6.  Kesler, R, Hertling, D (1983) Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods, 1st edition, Harper & Row, Pennsylvania, USA

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Cherye Roche

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