Look up at the stars, and not down at your feet….. (Stephen Hawking)

When we discuss Orthotics, we far too often make the assumption that this is all about the foot and ankle, perhaps the knee, and occasionally the hips. All of my posts thus far have really been focussed on the importance of skeletal stability in reducing, managing or preventing pain, and this does often begin with gait and posture. This situation isn’t helped when you consider that the good old ‘Functional Foot Orthosis’ (FFO) has become known as an ‘Orthotic’, thus fuelling the assumption that Orthotics is all about the foot; we need to be careful however, not to forget that the role of the Orthotist is to ‘straighten’ and to brace, and this is equally as important in all other parts of the body. What I want to do in this post, is to provide a whistle stop, and incredibly basic, introduction to the other types of orthoses that would be used from the pelvis up.

Your back supports your torso and head, and consists of 26 bones all with their own muscles and ligaments which allow you to bend forwards, backwards, side to side and also rotate round. Poor back health is a major issue with some staggering statistics. For example:

– Back pain will affect 80% of us at some point in our lives.
– One in six working days lost in the UK is due to back pain.
– It is estimated that back pain costs the NHS, business and the economy over £5 billion      a  year.

Back pain can occur due to damage to the bones, ligaments or muscles of the spine and can occur suddenly due to a trauma such as a whiplash injury or can be a chronic and degenerative condition such as arthritis. In any case the results are devastating to the sufferer.

We need to remember that the correct orthosis potentially has several jobs to do, ranging from immobilising specific body parts in order to promote the healing of tissue, correcting deformities, restricting motion to prevent harmful postures, to increasing the range of motion or strengthening muscle, thus it is crucial that the correct device is prescribed, and the appropriate advice given. Let’s begin with the lower spine, and specifically with what are called ‘Lumbasacral’ orthoses. These are generally used for issues with the lowest part of the spine, often for such conditions as Spondylolisthesis – this is a disease which causes one of the lower vertebrae to slip forward onto the bone directly beneath it. A Lumbasacral orthosis is usually used to prevent movement, thus preventing further damage or pain.

Scoliosis is something that more people may have heard of, and put simply, this is a curvature of the spine. This is, in the most serious cases, managed with surgery, but orthotics play their part here too. It is generally believed that where a spinal brace is used, in 80% of cases, the curve will remain the same size, thus sometimes removing the need for surgery for some. One of the big issues for researchers in recent years, has been how to develop a spinal brace that provides the right amount of immobilisation and support, whilst still permitting the wearer to function – even standing and sitting for example. Modern Orthoses are generally fantastic at doing both, but as they are all fitted to meet a specific need, the amount of bracing or movement you are permitted, will vary.

Moving up the spine to the neck, we move on to ‘Cervical Orthoses’, or more commonly known as the neck brace. These can range from soft collars, which are designed to provide support and to restrict movement, right up to a ‘Halo’ assembly, which can involve the head and the shoulders in order to brace a more serious neck injury for example. As with all bespoke orthoses, the type of brace prescribed will be determined by the specific requirements of the wearer, and whilst the anatomical needs will always take priority, the Orthotist will also take lifestyle into account where possible. There are a multitude of braces available today, and your Orthotist will discuss these with you if and when required.

We often refer to orthotic intervention in other areas above the pelvis, which don’t necessarily involve the spine, as ‘Upper Limb Orthotics’. These can cover issues with the shoulder, the elbow, the wrist, the hand or even individual fingers, and again, they are all designed to do different jobs, depending upon the needs of the wearer. Lehneis (1977) stated that the role of Orthotics is not only to enhance function, but to protect the limb in a functional position. This is particularly the case with upper limb Orthotics. Let us use ‘Lateral Epicondylitis’, or tennis elbow as you may know it better, as an example here. This can be treated with surgery or injections, but these are not risk free, and can have long-term effects. Wearing a simple Counterforce Orthotic brace however, keeps pressure off the inflamed muscles, by spreading the tension to different parts of your arm – thus enhancing function whilst protecting the damaged area in a functional position. A simple brace such as this, can keep people playing tennis and golf, which are the big two sports where this is  common, whilst removing the need for surgery or injections.

I know this is a awful lot to take in in one post, and I’m sure that I’ll revisit some of these in greater depth as time goes on, but I guess my point here is to take some of the focus off of the foot, and help us to realise that orthotics are for the whole body, not just for Christmas – whoops, sorry, I appear to have mixed my clichés! You are clearly not going to pop along to your Orthotist and ask for something as complex as a Halo neck brace, as this will undoubtedly be something that will be provided if required; however, how many people are living with back pain and thinking that there’s nothing that can be done, or worse, that surgery is the only option? How many people give up playing sports like tennis or golf because of excruciating pain, when actually, a chat with an Orthotist might see you back on the court or the green in no time? Make an appointment to see your Orthotist, and discuss what they might be able to do to help you reduce your pain.

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I wouldn’t want to be in your shoes………

‘You can’t understand someone until you’ve walked a mile in their shoes’ (Anon), is now quite a famous quote, and it gets rolled out frequently when discussing empathy. This is a ridiculous concept if you think about it, as how would walking in someone else’s shoes help you to understand anything about another human being? Well actually, now that I say this, I realise that the entire science of forensic orthotics is precisely this – ascertaining the identity of someone based upon their distinct gait pattern. Anyway, I digress. The main point here, is that shoes are a vital component in maintaining mobility; they are however, far more than this for many people. Shoes are an enormous fashion statement, and isn’t it true that a man can be judged by his shoes, his wallet and his watch? Probably not, but you get the point. Gone are the days when most people only had a solitary pair of shoes, and now most of us have numerous pairs. If you are lucky enough to be able to wear fashion shoes, without incurring great pain or a reduction in stability, then I take off my metaphorical hat to you, as this is not the case for many. If you are not in this group however, and you find shoes are either too shallow, too narrow, too heavy, too flexible, insufficiently supportive, too high, too low, or generally just a pain in the ‘tarsals’, then read on….

There are certain conditions that necessitate bespoke footwear, but this is not the topic for this month. What I want to discuss here, is the world of non-specialist, but sort-of-specialist footwear. If you have been diagnosed with Hallux Valgus, or a ‘bunion’ to you and me, or if you have arthritic feet, or even if you are prescribed a Functional Foot Orthosis, again, an insole to you and me, then you may need shoes with greater depth or width, either to accommodate the orthotic insole, or simply your foot itself. There are of course, many more reasons that you may need wider or deeper shoes, but the outcome is just the same.

Many people, faced with this issue, head for the High Street (other streets, roads and avenues are available), and they attempt to get the best fit possible given the circumstances. This sounds perfectly reasonable, until you consider that if the best you do is to compromise, then you may be making matters worse for your feet, which may already be delicate or in need of ‘protection’ where possible. The closest I can come to any kind of sensible analogy here, and bear with me, is for you to imagine borrowing your friends reading glasses to read a menu, because you’ve forgotten yours. This may be very useful in the very short term, but if you were to use these regularly, and they weren’t your prescription, then you are going to really damage your eyes. A pair of regular shoes will be OK in the short term, but are really not a sensible idea for any prolonged period. So, if this is the case, what can you do, because ‘special’ shoes are ugly right? WRONG!!

Orthotists are constantly signposting people to appropriate footwear, and I guess this is the issue – what is appropriate? There are some fantastic brands of footwear out there that claim to be for wider feet, and some are better than others. I’m going to stick my neck out here, and name a brand, which is not really what this blog is about, but I do feel that this is important. DB Shoes is a family business, and their humble beginnings in footwear began back in 1841. They make a bold claim, that they make the ‘Perfect fit for wider feet’ – quite a claim I’m sure you’d agree; it has to be said however, that their shoes are fantastic for anyone who needs a deeper or a wider shoe, and partly this is in the construction of the shoe itself, but also in the fact that they offer a number of different width and depth sizes. They are not unique in this, but they do have a best choice around in my experience.

Now I can hear you all thinking, well this is OK, but that’s no good if they all make me look like I’m 95 years old! This is simply not the case either, and whether you’re after a casual or smart shoe or boot, whether you’re 15 or 95, then they have styles that not only look good, but that also give you the room and the stability you need, and that your Orthotist has been begging you to get!

Advertisement over, the really important message here, is that whatever footwear you buy, it needs to fit correctly, and this is sadly something we pay little attention to. People believe that they are a certain shoe size, and henceforth, they buy shoes of that size, almost regardless. Any shoe manufacturer will tell you, that their finished products can range in size, and the most important thing to do, is to have the shoes ‘fitted’ – yes fitted. This isn’t simply trying them on and walking for a couple of paces, but actually having them fitted by an expert. A good shoe shop or footwear supplier will happily do this for you. If you need any advice on footwear, then speak to your Orthotist, and I’m sure they’ll point you in the right direction.

Anyway, the message here is to make sure that you wear appropriate footwear, and if this means stepping away from the high heels or ridiculous Kangaroo skin fashion boots, then make the leap, or if this is too ambitious, then maybe a shuffle as opposed to a leap. One thing is for certain – even expensive designer shoes look ridiculous if the wearer is hobbling along in them – function NOT fashion is the key here.

Keep on running……..

As the Spencer Davis Group so eloquently proclaimed in 1965, it is important, for some, to keep on running. So often, if someone who engages in sporting activity, as an enthusiastic amateur or a seasoned professional, succumbs to an injury, the greatest fear is that they’ll be told to give up doing whatever it was that caused the problem. For many, this results in their putting off what they believe to be the inevitable, choosing instead to carry on with an injury, causing further problems which may indeed then lead to them giving up. This does NOT need to be the case.

Sports injuries, or existing biomechanical issues that manifest themselves as pain whilst engaging in sporting activity, if caught and treated early enough, need not lead to giving up, or even in impaired performance. There are many orthotic interventions, most very simple, that can promote pain-free activity, increase confidence and reduce the chances of further injury.

Many kinds of sports, including running and ball sports in particular, have special movement sequences and loading patterns, which increase the risk of elevated stress and strain. It is possible, with the use of a bespoke orthotic insole for example, designed for your foot, but also for your sport and footwear, to reduce the risk of damage from overloading as much as possible, by supporting natural movements and at the same time preventing incorrect strain.
Many sports require a different range of movement, and therefore the strain is felt most at the ankle or the knee. Take tennis for example, where many professionals suffer from ankle injuries caused by the sudden explosion of, often lateral, movement, Simple, yet effective ankle orthoses worn on one, or both ankles can assist with stability and increase confidence. A certain former World Number 1 from north of the Border always wears these.

Hi impact sports such as skiing, surfing, cycling or motocross may require a knee brace, to both prevent injury and assist in recovery. There are many types of knee brace, all designed for a different purpose, and in order to get the type of brace best suited to your situation, an appointment with an orthotist is recommended.

I guess that the underlying message here, is that if you have a sporting injury, or an issue that is impairing your sporting activities, then you should really get checked out by a qualified and experienced Orthotist. It’s all, as I’ve mentioned before, about biomechanics, and they really are the specialists in this area. Short-term pain relief of whatever kind, might keep you going for a while – get you through that next match, run, swim or event – but if you want to avoid the dreaded ‘you need to give up’ conversation, then sorting whatever it was that caused you an issue in the first place, has to be the best option.

Have a nice trip?

Do you trip or stumble a little more than you think you should? If so, there’s a chance that this could be the result of ‘Foot Drop’.

Foot drop is a condition caused by weakness or paralysis of the muscles involved in the operation of lifting the front part of the foot. This is a particular issue when we walk, as this can lead to excessive tripping or falling, or pain caused as a result of the sufferer deliberately altering their gait pattern to avoid this. One common cause of foot drop, is an interruption of the signals from the brain to the peroneal nerve, and this is not unusual in people with Multiple Sclerosis (MS), spinal injuries or those who have suffered a stroke.
There are several ways that this can be managed, but one way is with a merging of orthotic technology with electrical stimulation. This doesn’t simply brace the limb to improve mobility, but instead using Myo-orthotic technology, restores the functionality of the impaired limb by recreating a natural nerve and muscle response producing only a slight tingling. The WalkAide FES system is worn on the skin, removing the need for implant surgery. This sounds like it could be an ordeal, but this really is modern technology doing its bit towards improving mobility, without any kind of invasive treatment, and with only a small cuff needing to be worn around the leg.
It may be that the orthotist would suggest a more rigid brace, such as a Carbon Fibre AFO (Ankle Foot Orthosis). Carbon fibre is an incredibly light, durable and hypoallergenic material. A carbon fibre AFO can provide a decrease in bulk and an increase in activity due to it’s ‘spring’ effect offering smoother and more natural gait. This option clearly doesn’t introduce the need for electronic stimulation, and whilst it might be a little more visible than the FES unit, is not bulky or unwieldy.
Some sufferers may find that a SAFO (Silicone Ankle Foot Orthosis) is more appropriate. This is a total contact silicone orthosis which incorporates the foot and ankle, and works by lifting the foot from above, as opposed to pushing from underneath as per traditional rigid braces. The SAFO gives support without interfering with normal biomechanics. This silicon brace is obviously less rigid, and can for some, be the perfect solution to the tripping issue.

Ultimately, it needs an Orthotist to assess your particular issue, and taking into account your lifestyle, other potential medical conditions, and your own personal preferences, they are best placed to prescribe the correct solution for you. Either way, all of these solutions, and others which might also be appropriate, are far better than tripping or falling on a regular basis, as this in many, can cause additional problems. So, if this is you, then make an appointment to see an Orthotist as soon as possible, as the next fall might just be the one that makes matters a whole lot worse!

It’s all about insoles………

So, it’s that time already, and a month has passed since my first ‘offerings’ about all things Orthotic. What I want to do in this post, is to try to make sense of some of the myth and hype that exists around orthotics, and particularly starting with the humble insole. You probably all know what an insole is, but just in case, it is an insert placed into footwear, sometimes simply for comfort, but often to rectify an issue and to provide some kind of support or stability. The word ‘Orthosis’ actually derives from Greek, and means ‘straightening out’, and whilst not all orthotics are about straightening, they are about bracing or providing stability. Anyway, so back to the insole……

I’ve already suggested that there is something of a hype or myth around insoles, and particularly at the moment. It’s not as if insoles are a new phenomenon, but like most other things, they are ‘big’ in the USA right now, and we tend to catch up eventually. Insoles vary in size, shape, materials, design, and possibly most importantly for many, cost. They are available off the shelf in large pharmacy chains in the UK very cheaply, but would you know what they were actually doing for you, and how would you know that they weren’t actually doing you more harm than good? The answer, unless you are clinically trained is of course, that you wouldn’t, until perhaps it was too late and more damage has been done. This is clearly the worst-case scenario, and the likelihood is that they won’t cause lasting damage, they just won’t necessarily do you any good either. Sadly, it’s not only cheap insoles that might not be doing you any good, as sometimes, the expensive ones are just as pointless, particularly if not prescribed correctly – more on this shortly so stay tuned! Some shoe shop chains, and increasingly sports footwear specialists, now offer to check your ‘gait’, in order to provide insoles for your shoes, be they work, leisure or sports-specific. These again can be made of a variety of materials, and can be costly.

The key to all of this, is the biomechanical assessment, and some of this refers back to my post last month, where I very briefly discussed what an ‘Orthotist’ is, how they’re trained and qualified, and what they can do for you. It’s no accident that there is a university degree course in Orthotics and Prosthetics (false limbs, and this will undoubtedly be the topic of this blog at some point into the future), and that this course permits those who have passed it, to register with the Health and Care Professions Council, or HCPC for short, and then allows them to go on to practice in the NHS or beyond. The HCPC registration is vital here, as this provides ‘protected status’ for qualified Orthotists, and means that someone who isn’t qualified, can NOT call themselves one. The Orthotist spends much of their time at university studying biomechanics, which I have mentioned briefly before, but which is the ‘scientific discipline which studies biological systems, such as the human body, by the methods of mechanical engineering’ (Whittle, 1991:34). This training allows the Orthotist to establish precisely what is causing someone’s issue, however serious, and to prescribe an appropriate intervention accordingly. Hopefully you have already identified, that if you purchase insoles from a pharmacist, a shoe shop, a sports shop, or actually from anyone who isn’t sufficiently qualified to prescribe them, then you are wasting your time and money, however much that might be.

It doesn’t necessarily follow that an assessment with a qualified and experienced Orthotist will result in a more expensive insole, just that it will result in you being prescribed the ‘right’ insole to meet your requirements. An Orthotist will also take lifestyle and social factors into account when prescribing, so if you make it clear that you are a runner, a gardener, play bowls, golf, have a dog, enjoy dancing and nights out, or even just enjoy sitting down and doing very little, then this will all be factored in to what is deemed to be most appropriate for you. I do need to make one thing very clear at this point, and that is whilst an Orthotist working in the NHS will also find this detail helpful in prescribing, the range of products made available by our fantastic health service is limited, and thus a visit to a private Orthotist will often mean that more options are available to those who can pay. This is a sad reality I guess, but isn’t new, as we now find this with eyecare, dentistry, audiology, physiotherapy, surgery……. the list goes on.

The reality for many, is that pain is something we often manage and live with, because we either don’t have time, or the money, or the knowledge as to where to seek help, and thus we endure it daily, with it often getting worse over time. We don’t do this with our cars however, and if we hear a noise, or our tyres get bald, then we are straight into the garage to get them fixed. You probably spend more time on your feet than you do in your car, so why not make arrangements to have a biomechanical MOT sometime soon – you know it makes sense.

The Journey Begins Indeed……..

Hi everyone. I say everyone, but as this is a brand new blog, the likelihood of anyone else out there reading it has to be slim surely! I need to begin with a brief explanation as to why I’m writing this blog, and what the intended purpose of it will be.

I work in a place called the Quays Orthotic Practice, which is situated in a beautiful setting, just on the outskirts of Lincoln in the UK. This is all fairly unremarkable stuff thus far I guess. The main issue, and the one thing many of you (there I go again, assuming there are ‘many’) will already be thinking, is ‘what on earth are orthotics, and what is an ‘Orthotist’? The reason this is not really well known, particularly in the UK yet, is that whilst there is provision for Orthotics within the National Health Service, this has often come under a variety of headings, and has been done through a number of different departments. Anyone from a consultant, to a podiatrist, to an appliance officer have at times, been seen as the people who provide ‘orthotics’.

In recent times however, this has primarily become the domain of the ‘Orthotist’ – a qualified and HCPC registered clinician, who has a specialist degree-level qualification, which makes them a specialist in biomechanics, and not simply of the lower limb. So what is biomechanics? If you consider the skeleton in terms of being a scaffold, then it holds up the body, and gives us form and stability. If a scaffold was not set or secured correctly, then it would be a shaky and unsafe structure; the same is true for the skeleton. If we don’t have a perfect ‘frame’, and most of us don’t, then we will encounter issues along the way. Effectively, the job of an Orthotist is to assist in bracing or strengthening our skeletal structure, in order that we are not ‘shaky’ ourselves. Much of the pain we live with, from the feet upwards to the neck and beyond, is potentially attributable to this unsound frame, and simple and often non-invasive assistance, reduces the pain, increases our mobility, and helps us lead happier lives all round.

Don’t get me wrong, orthotics aren’t miracle cures, but neither are they simple temporary pain relief. The aim here is to address the cause of the pain, thus reducing the need for other pain relieving interventions, such as medication, acupuncture, physiotherapy, massage, or simply ‘grinning and bearing it’!

What I hope to achieve through this blog, is to provide some details, on a monthly basis, about the kinds of issues we can encounter in terms of our general health and mobility, and discuss how orthotics can ‘often’ be a solution. This is NOT an aid to internet self-diagnosis, as this is the almost certain way to make a problem seem worse, or actually be worse with the incorrect intervention; it is instead designed to be an easy to read and digest guide to how orthotics can help, and potentially where you can go to seek the professional assistance you need.