Alecia Burchfiel

Women who seek to be equal with men lack ambition.

Overview


Pronation describes a slight inward rolling motion the foot makes during a normal walking or running stride. The foot (and ankle) roles slightly inward to accommodate movement. Some people, however, over-pronate and roll more than normal. With over-pronation, the arch of the foot flattens and causes excessive stress and pressure on the soft tissues of the foot. Over-pronation is more common in those with flat feet, and can lead to foot aches and pain, such as plantar fasciitis, Shin Splints and Knee Pain.Foot Pronation


Causes


Unless there is a severe, acute injury, overpronation develops as a gradual biomechanical distortion. Several factors contribute to developing overpronation, including tibialis posterior weakness, ligament weakness, excess weight, pes planus (flat foot), genu valgum (knock knees), subtalar eversion, or other biomechanical distortions in the foot or ankle. Tibialis posterior weakness is one of the primary factors leading to overpronation. Pronation primarily is controlled by the architecture of the foot and eccentric activation of the tibialis posterior. If the tibialis posterior is weak, the muscle cannot adequately slow the natural pronation cycle.


Symptoms


In addition to problems overpronation causes in the feet, it can also create issues in the calf muscles and lower legs. The calf muscles, which attach to the heel via the Achilles tendon, can become twisted and irritated as a result of the heel rolling excessively toward the midline of the body. Over time this can lead to inflexibility of the calf muscles and the Achilles tendon, which will likely lead to another common problem in the foot and ankle complex, the inability to dorsiflex. As such, overpronation is intrinsically linked to the inability to dorsiflex.


Diagnosis


A quick way to see if you over-pronate is to look for these signs. While standing straight with bare feet on the floor, look so see if the inside of your arch or sole touches the floor. Take a look at your hiking or running shoes; look for wear on the inside of the sole. Wet your feet and walk on a surface that will show the foot mark. If you have a neutral foot you should see your heel connected to the ball of your foot by a mark roughly half of width of your sole. If you over-pronate you will see greater than half and up to the full width of your sole.Pronation


Non Surgical Treatment


Orthotics are medical devices used to provide support to correct a physical abnormality. They can provide arch support when needed to remedy over-pronation, and in this particular cases the orthoses used are usually convenient shoe inserts. These can be taken in and out of shoes, and will be carefully tailored by your podiatrist to the specifics of your foot. It can take some weeks before the effects of the inserts can become truly noticeable, and in many cases your podiatrist will want to review your orthotics within a few weeks to make fine adjustments based on how well they have worked to reduce your pain.


Prevention


Strengthen the glutes to slow down the force of the foot moving too far inward. Most individuals who over-pronate have weak glute muscles and strengthening this area is a must. A simple exercise to strengthen glutes is lateral tube walking across a field/court/room. Place a lateral stretch band around your ankles and move your leg sideways while keeping your feet forward.
Overview


Sever?s Disease is one of the most common overuse sports injuries in the U.S. It may not receive the street cred that plantar fasciitis gets, but this painful condition affecting the heel routinely affects child athletes, usually from eight to thirteen years of age, right when the bones are coming together. The pounding force causes inflammation between the bones, according to YNN, as well as injury to the growth plates themselves. While the ?disease? classification may sound scary, it?s actually a quite normal overuse sports injury that does not typically persist into adulthood.


Causes


Predisposing Hereditary Factors: These are a biomechanical defect that one may be born with, which increases the chances of developing Sever's Disease. Short Achilles Tendon, When the Achilles Tendon is short from birth, it will exaggerate the tightness of this tendon that occurs during a child's growing years. This makes the pull of the Achilles Tendon on the heel's growth plate more forceful than normal, causing inflammation and pain, and eventually Sever's Disease. Short Leg Syndrome, When one leg is shorter than the other, the foot on the short leg must plantar flex (the foot and toes bend down) in order to reach the ground. In this way, the body tries to equalize the length of the legs. In order for the foot to plantar flex, the Achilles Tendon must pull on the heel with greater force than if the leg was a normal length. Thus the heel on the short leg will be more susceptible to Sever's Disease during the foot's growing years. Pronation. Is a biomechanical defect of the foot that involves a rolling outward of the foot at the ankle, so that when walking, the inner side of the heel and foot bears more of the body's weight than is normal (click here for more information about pronation). Pronation thus causes the heel to be tilted or twisted. In order for the Achilles Tendon to attach to the heel, it must twist to reach its normal attachment site. This will shorten or tighten the Achilles Tendon and increase the force of its pull on the heel's growth plate. This will increase the tightness of the Achilles Tendon during the foot's growing years, and may help to initiate bouts of Sever's Disease. Flat Arches and High Arches. Both of these biomechanical foot defects effect the pitch, or angle of the heel within the foot. When the heel is not positioned normally within the foot due to the height of the arch, the Achilles Tendon's attachment to the heel is affected. This may produce a shortening or tightening of the Achilles Tendon, which increases the force of its pull on the heel's growth plate. During the foot's growing years, abnormal arch height may contribute to the onset of Sever's Disease.


Symptoms


Sever?s disease is more common in boys. They tend to have later growth spurts and typically get the condition between the ages of 10 and 15. In girls, it usually happens between 8 and 13. Symptoms can include pain, swelling, or redness in one or both heels, tenderness and tightness in the back of the heel that feels worse when the area is squeezed. Heel pain that gets worse after running or jumping, and feels better after rest. The pain may be especially bad at the beginning of a sports season or when wearing hard, stiff shoes like soccer cleats. Trouble walking. Walking or running with a limp or on tip toes.


Diagnosis


You may have pain when your doctor squeezes your heel bone. You may have pain when asked to stand or walk on your toes or on your heels. You may have pain in your heel when your doctor stretches your calf muscles. Your doctor may order x-rays of the injured foot to show an active growth plate.


Non Surgical Treatment


Treatment aim is to lessen the load on the insertion of the Achilles tendon, along with pain relief if necessary. This can be achieved by modifying/reducing activity levels. Shoe inserts or heel raises. Calf stretches. Avoiding barefoot walking. Strapping or taping the foot to reduce movement. Orthotic therapy if due to biomechanical causes. Other treatment includes icing of the painful area to reduce swelling, pain medication if necessary and immobilisation of the affected limb in severe or long standing cases.


Surgical Treatment


The surgeon may select one or more of the following options to treat calcaneal apophysitis. Reduce activity. The child needs to reduce or stop any activity that causes pain. Support the heel. Temporary shoe inserts or custom orthotic devices may provide support for the heel. Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation. Physical therapy. Stretching or physical therapy modalities are sometimes used to promote healing of the inflamed issue. Immobilization. In some severe cases of pediatric heel pain, a cast may be used to promote healing while keeping the foot and ankle totally immobile. Often heel pain in children returns after it has been treated because the heel bone is still growing. Recurrence of heel pain may be a sign of calcaneal apophysitis, or it may indicate a different problem. If your child has a repeat bout of heel pain, be sure to make an appointment with your foot and ankle surgeon.
Overview


Leg length discrepancy, or as it has been alternatively termed, the short leg syndrome, is by far the most important postural asymmetry. Limb length discrepancy is simply defined as a condition where one leg is shorter than the other. If a substantial difference exists, disruptive effects on gait and posture can occur. Leg length discrepancy can be divided into two etiological groups. Structural. True shortening of the skeleton from congenital, traumatic or diseased origins. Functional. Development from altered mechanics of the lower body, such as foot hyperpronation or supination, pelvic obliquity, muscle/joint imbalances, poor trunk stabilization and deep fascial strain patterns.Leg Length Discrepancy


Causes


From an anatomical stand point, the LLD could have been from hereditary, broken bones, diseases and joint replacements. Functional LLD can be from over pronating, knee deformities, tight calves and hamstrings, weak IT band, curvature in the spine and many other such muscular/skeletal issues.


Symptoms


Patients with significant lower limb length discrepancies may walk with a limp, have the appearance of a curved spine (non-structural scoliosis), and experience back pain or fatigue. In addition, clothes may not fit right.


Diagnosis


The most accurate method to identify leg (limb) length inequality (discrepancy) is through radiography. It?s also the best way to differentiate an anatomical from a functional limb length inequality. Radiography, A single exposure of the standing subject, imaging the entire lower extremity. Limitations are an inherent inaccuracy in patients with hip or knee flexion contracture and the technique is subject to a magnification error. Computed Tomography (CT-scan), It has no greater accuracy compared to the standard radiography. The increased cost for CT-scan may not be justified, unless a contracture of the knee or hip has been identified or radiation exposure must be minimized. However, radiography has to be performed by a specialist, takes more time and is costly. It should only be used when accuracy is critical. Therefore two general clinical methods were developed for assessing LLI. Direct methods involve measuring limb length with a tape measure between 2 defined points, in stand. Two common points are the anterior iliac spine and the medial malleolus or the anterior inferior iliac spine and lateral malleolus. Be careful, however, because there is a great deal of criticism and debate surrounds the accuracy of tape measure methods. If you choose for this method, keep following topics and possible errors in mind. Always use the mean of at least 2 or 3 measures. If possible, compare measures between 2 or more clinicians. Iliac asymmetries may mask or accentuate a limb length inequality. Unilateral deviations in the long axis of the lower limb (eg. Genu varum,?) may mask or accentuate a limb length inequality. Asymmetrical position of the umbilicus. Joint contractures. Indirect methods. Palpation of bony landmarks, most commonly the iliac crests or anterior iliac spines, in stand. These methods consist in detecting if bony landmarks are at (horizontal) level or if limb length inequality is present. Palpation and visual estimation of the iliac crest (or SIAS) in combination with the use of blocks or book pages of known thickness under the shorter limb to adjust the level of the iliac crests (or SIAS) appears to be the best (most accurate and precise) clinical method to asses limb inequality. You should keep in mind that asymmetric pelvic rotations in planes other than the frontal plane may be associated with limb length inequality. A review of the literature suggest, therefore, that the greater trochanter major and as many pelvic landmarks should be palpated and compared (left trochanter with right trochanter) when the block correction method is used.


Non Surgical Treatment


Internal heel lifts: Putting a simple heel lift inside the shoe or onto a foot orthotic has the advantage of being transferable to many pairs of shoes. It is also aesthetically more pleasing as the lift remains hidden from view. However, there is a limit as to how high the lift can be before affecting shoe fit. Dress shoes will usually only accommodate small lifts (1/8"1/4") before the heel starts to piston out of the shoe. Sneakers and workboots may allow higher lifts, e.g., up to 1/2", before heel slippage problems arise. External heel lifts: If a lift of greater than 1/2" is required, you should consider adding to the outsole of the shoe. In this way, the shoe fit remains good. Although some patients may worry about the cosmetics of the shoe, it does ensure better overall function. Nowadays with the development of synthetic foams and crepes, such lifts do not have to be as heavy as the cork buildups of the past. External buildups are not transferable and they will wear down over time, so the patient will need to be vigilant in having them repaired. On ladies' high-heel shoes, it may be possible to lower one heel and thereby correct the imbalance.


LLD Insoles


Surgical Treatment


Surgical treatments vary in complexity. Sometimes the goal of surgery is to stop the growth of the longer limb. Other times, surgeons work to lengthen the shorter limb. Orthopedic surgeons may treat children who have limb-length conditions with one or a combination of these surgical techniques. Bone resection. An operation to remove a section of bone, evening out the limbs in teens or adults who are no longer growing. Epiphyseal stapling. An operation to slow the rate of growth of the longer limb by inserting staples into the growth plate, then removing them when the desired result is achieved. Epiphysiodesis. An operation to slow the rate of growth of the longer limb by creating a permanent bony ridge near the growth plate. Limb lengthening. A procedure (also called distraction osteogenesis or the Ilizarov procedure) that involves attaching an internal or external fixator to a limb and gradually pulling apart bone segments to grow new bone between them. There are several ways your doctor can predict the final LLD, and thus the timing of the surgery. The easiest way is the so-called Australian method, popularised by Dr. Malcolm Menelaus, an Australian orthopedic surgeon. According to this method, growth in girls is estimated to stop at age 14, and in boys at age 16 years. The femur grows at the rate of 10 mm. a year, and the upper tibia at the rate of 6 mm. a year. Using simple arithmetic, one can get a fairly good prediction of future growth. This of course, is an average, and the patient may be an average. To cut down the risk of this, the doctor usually measures leg length using special X-ray technique (called a Scanogram) on three occasions over at least one year duration to estimate growth per year. He may also do an X-ray of the left hand to estimate the bone age (which in some cases may differ from chronological age) by comparing it with an atlas of bone age. In most cases, however, the bone age and chronological age are quite close. Another method of predicting final LLD is by using Anderson and Green?s remaining growth charts. This is a very cumbersome method, but was till the 1970?s, the only method of predicting remaining growth. More recently, however, a much more convenient method of predicting LLD was discovered by Dr. Colin Moseley from Montreal. His technique of using straight line graphs to plot growth of leg lengths is now the most widely used method of predicting leg length discrepancy. Whatever method your doctor uses, over a period of one or two years, once he has a good idea of the final LLD, he can then formulate a plan to equalize leg lengths. Epiphyseodesis is usually done in the last 2 to 3 years of growth, giving a maximum correction of about 5 cm. Leg lengthening can be done at any age, and can give corrections of 5 to10 cm., or more.