Isadora Youse
I am not only a pacifist but a militant pacifist. I am willing to fight for peace.
The Treatment Of Over-Pronation
Overview


Often misunderstood, pronation is considered by many to be a negative attribute; pronation is actually a good thing in the correct amount. Pronation is the body's response to the ground forces incurred during running and walking. When the foot impacts the ground, the arch elongates and flattens, which allows the foot to roll inward. This action helps the body to absorb shock. The degree to which the arch flattens is often associated with the degree the foot pronates. An ideal foot-strike is said to be neutral and is characterized by slight inward movement of the ankle-bone during stance (when the foot is in contact with the ground). Most runners for example exhibit over-pronation in varying degrees. 50-60% of runners exhibit mild to moderate over-pronation and are best suited for support orthotics. 20-30% of runners exhibit severe over-pronation and are best suited for motion control shoes.Overpronation


Causes


Over-pronation occurs when the foot collapses too far inward stressing the plantar fascia (the area underneath the arch of the foot.) Normally, one pronates every time he or she walks, but excessive pronation is called over-pronation. When this occurs it can cause pain in the feet, knees, hips, low back and even the shoulder. Decreasing over-pronation, which is very prominent in runners, will help add endurance, speed and efficiency to your run and ultimately place less stress on your body.


Symptoms


Overpronation can be a contributing factor in other lower extremity disorders, such as foot pain, plantar fasciitis, ankle injuries, medial tibial stress syndrome (shin splints), periostitis, stress fractures and myofascial trigger points. Overpronation increases the degree of internal tibial rotation, thereby contributing to various knee disorders such as meniscal injury or ligament sprains. The effects of the postural deviation are exaggerated in athletes due to the increase in foot strikes while running and the greater impact load experienced. When running, three to four times the body weight is experienced with each foot strike.2 If overpronation exists, the shock force is not adequately absorbed by the foot and is transmitted further up the kinetic chain.


Diagnosis


To easily get an idea of whether a person overpronates, look at the position and condition of certain structures in the feet and ankles when he/she stands still. When performing weight-bearing activities like walking or running, muscles and other soft tissue structures work to control gravity's effect and ground reaction forces to the joints. If the muscles of the leg, pelvis, and feet are working correctly, then the joints in these areas such as the knees, hips, and ankles will experience less stress. However, if the muscles and other soft tissues are not working efficiently, then structural changes and clues in the feet are visible and indicate habitual overpronation.Over-Pronation


Non Surgical Treatment


When you see the doctor, he or she will likely perform a complete examination of your feet and watch you walk. The doctor will need to take x-rays to determine the cause of your flat feet. In some cases, further imaging may be needed, especially if your symptoms are severe and sudden in nature. Once you are properly diagnosed, your doctor will create an appropriate treatment plan. There are several options to correct overpronation, such as orthotics. In many cases, overpronation can be treated with non-surgical methods and over-the-counter orthotics. In severe cases, however, custom-made orthotics may work better. Orthotics provide arch support and therefore prevent collapse of the arch with weight bearing. They are made of materials such as spongy rubber or hard plastic. Your doctor will also want to examine your footwear to ensure they fit properly and offer enough medial support. Extra support and stability can be achieved with footwear that has a firm heel counter. If you are experiencing pain, you should be able to use over-the-counter pain medications such as ibuprofen to relieve symptoms.


Surgical Treatment


The MBA implant is small titanium device that is inserted surgically into a small opening between the bones in the hind-mid foot: the talus (ankle bone) and the calcaneus (heel bone). The implant was developed to help restore the arch by acting as a mechanical block that prevents the foot from rolling-in (pronation). In the medical literature, the success rate for relief of pain is about 65-70%. Unfortunately, about 40% of people require surgical removal of the implant due to pain.
What Exactly Is Severs Disease?
Overview


One of the most important things to know about Sever's disease is that, with proper care, the condition usually goes away within 2 weeks to 2 months and does not cause any problems later in life. Most children can return to physical activity without any trouble once the pain and other symptoms go away. The risk of recurrence goes away on its own when foot growth is complete and the growth plate has fused to the rest of the heel bone, usually around age 15.


Causes


Apart from age, other factors that may contribute to developing Sever?s disease include physical activity, any form of exercise that is weight bearing through the legs or stresses the soft tissue can exacerbate the pain of the disease. External factors, for example, running on hard surfaces or wearing inappropriate shoes during sport. Overuse injury, very active children may repeatedly but subtly injure the bones, muscles and tendons of their feet and ankles. In time, the accumulated injuries cause symptoms.


Symptoms


The pain is at the heel or around the Achilles tendon. This is felt commonly during exercise, particularly activities involving running or jumping. The back of the heel may also be tender to touch and there may be localised swelling. There may be stiffness in the calf muscles first thing in the morning and you may notice limping or a tendency to tiptoe.


Diagnosis


The x-ray appearance usually shows the apophysis to be divided into multiple parts. Sometimes a series of small fragments is noted. Asymptomatic heels may also show x-ray findings of resporption, fragmentation and increased density. But they occur much less often in the normal foot. Pulling or ?traction? of the Achilles tendon on the unossified growth plate is a likely contributing factor to Sever?s disease. Excessive pronation and a tight Achilles and limited dorsiflexion may also contribute to the development of this condition.


Non Surgical Treatment


In mild cases, elevating the heel through heel lifts in the shoes and decreasing activity level may be enough to control the pain. In more severe cases, orthotic therapy to help control the motion of the heel, as well as icing, elevating, and aspirin therapy may be required to alleviate the symptoms. In those children who do not respond to either therapy mentioned above, it is sometimes necessary to place the child in a below-knee cast for a period of 4-6 weeks. It is important for both the child and parents to understand that the pain and swelling associated with this disorder should resolve once the growth plate has fused to the primary bone in the heel.


Exercise


For children with Sever's disease, it is important to habitually perform exercises to stretch the hamstrings, calf muscles, and the tendons on the back of the leg. Stretching should be performed 2-3 times a day. Each stretch should be performed for 20 seconds, and both legs should be stretched, even if the pain is only in one heel. Heel cups or an inner shoe heel lifts are often recommended for patient suffering from Sever's disease. Wearing running shoes with built in heel cups can also decrease the symptoms because they can help soften the impact on the heel when walking, running, or standing.
Acute Achilles Tendon Rupture Surgery Rehab

Overview
Achilles Tendon
Achilles tendon rupture is most common in people aged 30-50. Patients may describe the injury as feeling or hearing a snap or bang, or as feeling they have been shot in the back of the leg. On examination, patients will have reduced plantarflexion and a positive Thompson test. Surgery is associated with a lower risk of re-rupture and a greater likelihood of returning to sporting activity. Conservative management reduces the chance of complications.

Causes
Your Achilles tendon helps you point your foot downward, rise on your toes and push off your foot as you walk. You rely on it virtually every time you move your foot. Rupture usually occurs in the section of the tendon located within 2.5 inches (6 centimeters) of the point where it attaches to the heel bone. This section may be predisposed to rupture because it gets less blood flow, which may impair its ability to heal. Ruptures often are caused by a sudden increase in the amount of stress on your Achilles tendon. Common examples include increasing the intensity of sports participation, falling from a height, stepping into a hole.

Symptoms
A sudden and severe pain may be felt at the back of the ankle or calf, often described as "being hit by a rock or shot" or "like someone stepped onto the back of my ankle." The sound of a loud pop or snap may be reported. A gap or depression may be felt and seen in the tendon about 2 inches above the heel bone. Initial pain, swelling, and stiffness may be followed by bruising and weakness. The pain may decrease quickly, and smaller tendons may retain the ability to point the toes. Without the Achilles tendon, though, this would be very difficult. Standing on tiptoe and pushing off when walking will be impossible. A complete tear is more common than a partial tear.

Diagnosis
A doctor will look at the type of physical activity you have been doing. He or she will then look at your foot, ankle and leg. An MRI may also be used. This is to help determine the severity of the tear and the extent of separation of the fibers.

Non Surgical Treatment
Non-surgical treatment of Achilles tendon rupture is usually reserved for patients who are relatively sedentary or may be at higher risk for complications with surgical intervention (due to other associated medical problems). This involves a period of immobilization, followed by range of motion and strengthening exercises; unfortunately, it is associated with a higher risk of re-rupture of the tendon, and possibly a less optimal functional outcome.
Achilles Tendinitis

Surgical Treatment
Unlike other diseases of the Achilles tendon such as tendonitis or bursitis, Achilles tendon rupture is usually treated with surgical repair. The surgery consists of making a small incision in the back part of the leg, and using sutures to re-attach the two ends of the ruptured tendon. Depending on the condition of the ends of the ruptured tendon and the amount of separation, the surgeon may use other tendons to reinforce the repair. After the surgery, the leg will be immobilized for 6-8 weeks in a walking boot, cast, brace, or splint. Following this time period, patients work with a physical therapist to gradually regain their range of motion and strength. Return to full activity can take quite a long time, usually between 6 months and 1 year.

Leg Length Discrepancy And Running Performance
Overview


Surgical lengthening of the shorter extremity (upper or lower) is another treatment option. The bone is lengthened by surgically applying an external fixator to the extremity in the operating room. The external fixator, a scaffold-like frame, is connected to the bone with wires, pins or both. A small crack is made in the bone and tension is created by the frame when it is "distracted" by the patient or family member who turns an affixed dial several times daily. The lengthening process begins approximately five to ten days after surgery. The bone may lengthen one millimeter per day, or approximately one inch per month. Lengthening may be slower in adults overall and in a bone that has been previously injured or undergone prior surgery. Bones in patients with potential blood vessel abnormalities (i.e., cigarette smokers) may also lengthen more slowly. The external fixator is worn until the bone is strong enough to support the patient safely, approximately three months per inch of lengthening. This may vary, however, due to factors such as age, health, smoking, participation in rehabilitation, etc. Risks of this procedure include infection at the site of wires and pins, stiffness of the adjacent joints and slight over or under correction of the bone?s length. Lengthening requires regular follow up visits to the physician?s office, meticulous hygiene of the pins and wires, diligent adjustment of the frame several times daily and rehabilitation as prescribed by your physician.Leg Length Discrepancy


Causes


Leg length discrepancies can be caused by poor alignment of the pelvis or simply because one leg is structurally longer than the other. Regardless of the reason, your body wants to be symmetrical and will do its best to compensate for the length difference. The greater the leg length difference, the earlier the symptoms will present themselves to the patient. Specific diagnoses that coincide with leg length discrepancy include: scoliosis, lumbar herniated discs, sacroiliitis, pelvic obiliquity, greater trochanteric bursitis, hip arthritis, piriformis syndrome, patellofemoral syndrome and foot pronation. Other potential causes could be due to an injury (such as a fracture), bone disease, bone tumors, congenital problems (present at birth) or from a neuromuscular problem.


Symptoms


If your child has one leg that is longer than the other, you may notice that he or she bends one leg. Stands on the toes of the shorter leg. Limps. The shorter leg has to be pushed upward, leading to an exaggerated up and down motion during walking. Tires easily. It takes more energy to walk with a discrepancy.


Diagnosis


A qualified musculoskeletal expert will first take a medical history and conduct a physical exam. Other tests may include X-rays, MRI, or CT scan to diagnose the root cause.


Non Surgical Treatment


Heel lifts Raise the heel on the shorter leg. It is applied either to the heel of the custom orthotic or to the inside of the shoe under the insole at the heel. Generally if the discrepancy is greater than 3/8 of an inch, the modification is applied externally on the footwear. Custom made orthotics help to provide proper support and alignment to the foot, controlling conditions such as over pronation. Orthopedic Footwear, properly fitted, to which a lift might be applied inside or out.


LLD Shoe Inserts


Surgical Treatment


Surgeries to lengthen a leg are generally only performed when there is a difference in leg length of greater than four centimeters. These types of surgeries can be more difficult and have more complications, such as infections, delayed healing, dislocations, and high blood pressure. In a several step process, bone lengthening surgeries involve cutting a bone in two in order to allow new bone growth to occur. After the bone is cut, a special apparatus is worn with pins that will pull the bone apart at approximately one millimeter per day. This causes osteogenesis, or new bone growth, in between the cut bone segments. A cast or brace may be required for several months after surgery to allow the new bone growth to harden and provide extra support.
Will Posterior Tibial Tendon Dysfunction Always Require Surgical Teatment ?

Overview
There are four stages of posterior tibial tendon dysfunction. In the first stage the posterior tibial tendon is inflamed but has normal strength. There is little to no change in the arch of the foot. In stage two the tendon is partially torn or shows degenerative changes and as a result loses strength. There is considerable flattening of the arch without arthritic changes in the foot. Stage three results when the posterior tibial tendon is torn and not functioning. As a result the arch is completely collapsed with arthritic changes in the foot. Stage four is identical to stage three except that the ankle joint also becomes arthritic.
Acquired Flat Feet

Causes
Flat feet causes greater pressure on the posterior tibial tendon than normal. As the person with flat feet ages, the muscles, tendons and ligaments weaken. Blood supplies diminish as arteries narrow. These conditions are magnified for obese patients because of their increased weight and atherosclerosis. Finally, the tendon gives out or tears. Most of the time, this is a slow process. Once the posterior tibial tendon and ligaments stretch, body weight causes the bones of the arch to move out of position. The foot rotates inward (pronation), the heel bone is tilted to the inside, and the arch appears collapsed. In some cases, the deformity progresses until the foot dislocates outward from the ankle joint.

Symptoms
Some symptoms of adult acquired flat foot are pain along the inside of the foot and ankle, pain that increases with activity, and difficulty walking for long periods of time. You may experience difficulty standing, pain on the outside of the ankle, and bony bumps on the top of the foot and inside the foot. You may also have numbness and tingling of the feet and toes (may result from large bone spurs putting pressure on nerves), swelling, a large bump on the sole of the foot and/or an ulcer (in diabetic patients). Diabetic patients should wear a properly fitting diabetic shoe wear to prevent these complications from happening.

Diagnosis
Examination by your foot and ankle specialist can confirm the diagnosis for most patients. An ultrasound exam performed in the office setting can evaluate the status of the posterior tibial tendon, the tendon which is primarily responsible for supporting the arch structure of the foot.

Non surgical Treatment
Conservative treatment is indicated for nearly all patients initially before surgical management is considered. The key factors in determining appropriate treatment are whether acute inflammation and whether the foot deformity is flexible or fixed. However, the ultimate treatment is often determined by the patients, most of whom are women aged 40 or older. Compliance can be a problem, especially in stages I and II. It helps to emphasise to the patients that tibialis posterior dysfunction is a progressive and chronic condition and that several fittings and a trial of several different orthoses or treatments are often needed before a tolerable treatment is found.
Flat Feet

Surgical Treatment
Surgical correction is dependent on the severity of symptoms and the stage of deformity. The goals of surgery are to create a more functional and stable foot. There are multiple procedures available to the surgeon and it may take several to correct a flatfoot deformity. Usually surgical treatment begins with removal of inflammatory tissue and repair of the posterior tibial tendon. A tendon transfer is performed if the posterior tibial muscle is weak or the tendon is badly damaged. The most commonly used tendon is the flexor digitorum longus tendon. This tendon flexes or moves the lesser toes downward. The flexor digitorum longus tendon is utilized due to its close proximity to the posterior tibial tendon and because there are minimal side effects with its loss. The remainder of the tendon is sutured to the flexor hallucis longus tendon that flexes the big toe so that little function is loss.