On February  21st, the Free Your Feet team held the first ever children’s event at Sylvan Elementary School. Over 175 students received brand new shoes at no cost. The event was a huge success thanks to dozens of volunteers, community support and donations. Thank you.

Notable news coverage:

- School children get free shoes to stay active, healthy

- 170 students receive new athletic shoes

- Students Get The Perfect Shoe, Free Of Charge

Thank you for all that you do.

The Free Your Feet Team

Here, we will attempt to identify some of the normal stages of foot development and offer recommendations for when to intervene. But, as a word of caution, the most critical red flag that a parent should heed is a frequent complaint of pain in the foot, ankle or leg. Such pain should always be investigated even when there are no apparent abnormalities of the foot. And, while every child is different, there are some family and genetic predispositions, such as a history of plantar fasciitis, which may make early intervention more pressing.

Static foot abnormalities: When are ‘flat feet’ okay?
Children begin life without a defined arch to their foot. Arches usually develop at some point between the ages of three and five, but the exact time is often influenced by the presence or absence of footwear, obesity and gender. Flexible flat feet – feet that are flat when standing but show an arch when seated – should be evaluated and monitored. Treatment may be necessary if the condition worsens or becomes symptomatic.

There are many health care professionals skilled in evaluating bony deformities of the foot and their impact on the child’s walking gait. Physical therapists, pedorthists, podiatrists and pediatricians have unique skills that allow them to interpret a number of problems with the musculoskeletal system and carefully consider the extent of the problem and treatment strategies.

Pigeon Toes
In-toeing, commonly called pigeon toes, is a condition in which a child’s toes point inward and can be caused by problems with hip or lower leg rotation, the feet or the nerves and muscles. Most children outgrow the tendency to in-toe by two years of age. If the problem persists long after and is accompanied by tripping over the feet, general clumsiness and difficulty finding well-fitting shoes, parents should seek the help of a pediatrician, physical therapist or pedorthist. There are a variety of treatment strategies such as stretching, special-made shoes or other corrective devices to alleviate difficulties with sports or other daily physical activity.

Out-toeing
Normal walking patterns involve a slight amount of out-toeing, but if your child has a Charlie Chaplin walk that persists beyond two years old, they should be evaluated for any problems stemming from the hip, thigh, lower leg or feet. Many children who exhibit out-toeing also have flat feet. In those cases, orthoses can be used as early as the age of eight, but caution should be taken. Special supportive shoes with flares and wedges can also help with correcting alignment to some degree.

Toe walking
Toe walking (equinus gait) is often seen in young children, particularly if they have just begun to walk; however, it can be a sign of a condition that requires further evaluation – especially if ankle motion is limited. In most cases, toe walking is a habit that the child will outgrow, but it can be caused by neuromuscular conditions, such as cerebral palsy or muscular dystrophy, leg length differences, spinal cord abnormalities and achilles tendon shortness. If there is a mild shortness of the Achilles tendon, stretching exercises and/or physical therapy may be necessary. If the toe walking is more severe or persistent, then other options, including casting, botox injections or surgery should be considered. All cases of toe walking should be evaluated to rule out the causes other than just habit.

Bow-legs
Bow-leggedness, known in medical parlance as tibial varum, is a condition in which there is a wide space between a child’s thighs and ankle when standing with the feet together. This space is caused by excessive bowing of the long bones of the lower leg. Though this bony anomaly is not a great cause for alarm, it may create some compensations of the placement of the foot that will necessitate orthoses later in life. If the angulation is on both sides and worsens over time, however, children should be screened for Blount’s disease. In this condition, the growth plate of the top of the long bone over the toe bone grows on the outer side but ceases growth on the inner side leading to excessive bowing.

So what can you do?
Begin to take care of your baby’s feet early. Clean, well-protected feet are critical for babies from day one. Preventative care can truly help your child have happy, healthy feet throughout their lives. At birth, a child’s foot has 20 bones; By age two, the number increases to 26. Children’s feet need freedom to grow, but they should be protected from blisters and other injuries.

Although shoes are helpful in preventing injury, always wearing them indoors provides too much support that may prevent muscles from developing properly. Outdoor shoes, while somewhat more protective, should not be too rigid, as children’s feet must be able to adapt to different surfaces. Properly fitting socks and shoes are often taken for granted, but it is the most important piece of the puzzle for injury prevention. Frequent measurement by a qualified pedorthist or shoe fitter is essential.

When to see the doctor for a foot evaluation?
Where does that leave a parent? Most concerning are pains felt when standing, walking or running. These are commonly caused by biomechanical imbalances that create instability of the leg and foot and should be evaluated by a pediatrician, physical therapist or podiatrist. As previously indicated, very young children have difficultly articulating the pain; whereas, older children may withdraw from sports or other physical activities because of lack of coordination or just not feeling right. In such cases, get a check up instead of simply waiting for your child to grow out of these painful or awkward foot issues. Your little one will thank you!

Free Your Feet Holiday Event Summary

On November 17th, the Free Your Feet team held a second event at University Physical Therapy in Hillsborough. The Free Your Feet Holiday Edition was a huge success, thanks to hundreds of volunteers, immense community support and numerous substantial donations. With your help, we impacted nearly three times more people than the first event – all in eight short hours. Thank you.

Shoe Donations

- 200 pairs donated by Aetrex

- 132 pairs donated by New Balance for Children

- 75 pairs donated by Wake Forest Baptist Church

- 15 pairs purchased by FootCentric from FootSolutions and New Balance ($860.00)

- 3 children’s shoes purchased with a contribution from Wake Forest ($150.00)

- $51 used to defray expenses for shoes came from FootCentric’s fashion show fundraiser at FootSolutions

Shoe Disbursement

- 73 pairs of shoes were issued to people in need, 58 of which came from New Balance, Aetrex and Wake Forest Baptist Church

- 30 pairs were gently-used or like new donations from Omega Sports, FootSolutions, Murdoch Developmental Center, New Balance and the Wake Forest Baptist Church

Key Support

- The North Carolina Physical Therapy Association provided shoe storage prior to the event

- 32 pairs were repaired by H and H Shoe Repair in Raleigh

- 30 pairs of socks were donated courtesy of the North Carolina Physical Therapy Association

- 28 volunteers worked a whopping 229 hours over 2 days

- 4 clinical teams comprised of a physical therapist, certified pedorthist and two graduate PT students lent their time and skills

- 8 administrative volunteers provided support from check-in to check-out

We are so pleased to report that we were able to donate 125 pairs of shoes that were not appropriate for therapeutic footwear to the Mebane Touch of Warmth Ministry for homeless and disadvantaged individuals.

Each of you played a key role in the success of Free Your Feet – Holiday Edition. Through the combined outpouring of effort, kindness and donations, we helped over 100 people this holiday season. Thank you so much for your continued support to bring Free Your Feet to the people of North Carolina.

Warmest regards and happy holidays!

The Free Your Feet Team

The Free Your Feet Project

FootCentric is proud to partner with the University of North Carolina Physical Therapy Faculty Clinic and the North Carolina Physical Therapy Association to bring medical assessment and therapeutic footwear to North Carolina residents in need.

Fittings 

Individuals who qualify for the Free Your Feet Project will be fitted for shoes by accredited physical therapists at the University Physical Therapy Clinic at 400 Millstone Drive, Hillsborough, NC on June 2, 2012. Qualified patients will not be required to pay for the foot assessment, consultation, fitting or shoes (up to one pair per person).

How to Help

Proceeds from the first annual Fit for Fashion Show on April 29 in Chapel Hill will go towards supporting the Free your Feet Project. Attendees at the event are encouraged to bring a pair of gently used shoes to donate to the cause. We are also accepting donations of socks at the North Carolina Physical Therapy Association Spring Conference.

If you cannot attend the show but would still like to help, you may donate your shoes at any of the Free Your Feet drop boxes located in the following Triangle area stores:

Omega Sports – 8200 Renaissance Pkwy, Durham, NC 27713
New Balance, Raleigh-Durham – 6807 Fayetteville Rd # 120 Durham, NC 27713
Foot Solutions, Raleigh – 8531 Brier Creek Parkway Raleigh, NC 27617
Armstrong Podiatry & Sports Health – 2206 Page Rd, Durham, NC 27617

We are in need of volunteers to help sort and catalogue shoes on April 13. Please email pat@footcentriconline.com or call 919.433.7515 for details.

And, please help us spread the word about the show, course and the great cause!

The Free Your Feet Project and Fit for Fashion Show are generously supported by:

• Aetrex Worldwide
• Armstrong Podiatry & Sports Health
• Comprehensive Physical Therapy Center
• Foot Solutions, Raleigh
• H and H Shoe Repair
• New Balance, Raleigh-Durham
• Omega Sports
• The Stock Exchange

Bruce Buley, PT, explains how to properly identify and evaluate 

Q.    In your opinion, why is it important to differentiate between tendinitis and tendinosis?

It is important to differentiate between the two because the treatments are different. For tendinitis, rest and anti-inflammatories are  necessary to heal the tissue; in tendinosis, there is an atrophic quality to the tissue in which no mast or inflammatory cells are seen histologically (Alfredson et al). As a result, the tissue needs to be reconditioned, but the rate and intensity of the reconditioning depends on the patient.

In patients suffering from Achilles tendinosis, neovascularization appeared to contribute to continued pain, and another study conducted by Ohbey and Alfredson (2002) found that sclerosing new blood vessels seemed to decrease pain.

In an acute tendinitis that does not respond to treatment of modalities, the use of a walking boot for six weeks to optimize rest through immobilization followed by active rehab is recommended.

Q.    What evidence-based protocols do you use for Achilles tendinosis? What is your personal experience with the success of these protocols?

Alfredson et al. is the primary protocol for Achilles tendinosis though there have been some modifications regarding the extent of excursion of eccentrics depending on whether the pain is located either the insertion or the midpoint of the tendon.

Q.    Do you see any negative effects from these protocols? Can you site any contraindications?

The “dicey” issue is accurately distinguishing between a tendinosis and a tendinitis. Generally speaking, longer-standing Achilles pain is usually associated with a tendinosis whereas a shorter-term problem is more likely tendinitis.

Q.    Do you use lifts in shoes for this problem? For what length of time?

I often use lifts based on the mechanical logic that the tendon works less when it does not have to push through a great range of motion in acute Achilles tendinitis. I have also used a medial rear-foot wedge to help valgus at the heel strike. The idea is to decrease medial strain at the Achilles tendon as the heel goes into valgus (Donnatelli et al.).

In general, I will use the heel lift for as long as the pain is present. When pain is eliminated, reconditioning is necessary to reestablish full excursion functionally of the tendon.

Q.    Do you ever use orthoses for this problem? What is the most common prescription that you use (control for pronation, supination, equinus)?

Orthoses can be helpful when the gait pattern has a significant pronatory quality. I have also used orthoses for supinators, though much less often as they are much less frequent in their presentation. I have not done orthoses for equinus patients with Achilles tendinosis.

Bruce Buley is the Clinic Director at Comprehensive Physical Therapy Center (CPTC) in Chapel Hill, NC. Bruce received his physical therapy training at downstate Medical Center in New York City and earned an advanced Master’s in physical therapy at UNC-CH. His 30 years of physical therapy experience have included treating patients with orthopedic, neurological, cardiac, pediatric and sports related problems, including foot and orthotic fabrication.

Read more about Bruce and his practice: http://cptc-nc.com/.

The most common problems are:

– Pain in the great toe area (hallux limitus or rigidus)

– Pain under the ball of the foot (metatarsalgia)

– Bunions (hallux abducto-valgus)

These changes can significantly impair mobility and are often associated with falls in the older population. So, how do such biomechanical changes come about? And what, if anything, can be done to reduce loss of function and subsequent disability?

There is hope. Although aging is associated with a loss of elasticity in the pads of our feet, there are ways to improve walking comfort. Proper shoe choice, the use of inserts and metatarsal and heel pads have all been shown to increase walking distance while reducing pain (Arthritis Care Research, 917-973)

While there are many places to turn for help including drug stores and mail order catalogues, the judicious use and proper placement of pressure-relieving pads for pain in the heel and under the ball of the foot is critical. Much to my dismay, I have seen patients place a wide variety of items in their shoes in an attempt to relieve pressure and pain – all without a pressure map foot scan or even concern for proper placement. However innocuous to the casual observer, improper placement of shoe pads can redistribute pressure to other parts of the foot or even the body and lead to disastrous consequences.

Interested? Read more about our take on women and foot pain in the February issue of Natural Awakenings Triangle.

References: Arthritis Care Research. (2010). 62(7), 917-973.

Q.    How prevalent is arthritis in your practice?

A.    Extremely common. Approximately 75-80 percent of patients with rheumatoid arthritis complain of pain and swelling. Many cannot walk or continue to do normal activities of daily living. Within various populations, there are varying levels of disability. About one half of my osteoarthritic patients have foot pain, the other groups with a high level of pain and disability are fibromyalgia patients and patients with connective tissue disease.

 The fibromyalgia patients have pain from their scalp to their toes. They have multiple trigger points around the peroneus brevis, longus and tertius tenons. These trigger points can also produce ankle pain without injury, or any previous sprain or fracture.

Q.    What helps these patients?

A.      I am not sure if this sounds negative but nothing really helps. I have tried cortisone shots, oral and topical anti-inflammatory medications, other forms of therapies, but these are not very effective or long lasting.

Q.    How do you explain the recalcitrant nature of foot pain in arthritic patients?

A.      I think that the high force of weight bearing along with the nature of the disease [arthritis] causes the deformity to be acquired. There are micro injuries and inflammation around the surrounding tissues with high input to the inflammatory receptors. There is also the very high prevalence of co-morbidities with foot pain. Diabetics can frequently develop dropped arch, and patients with Peripheral neuropathy can suffer from overwhelming pain and sensory changes.

Q.    Are there any forms of therapy you find particularly helpful?

A.      Physical therapy and pedorthic attention to footwear is very important. One of the most effective ways to address foot pain is to teach people how to walk with proper shoes and inserts.

Kinga M. Vereczkey is a board-certified Rheumatologist and the Medical Director of the Sanford Specialty Clinics for the University of North Carolina Hospitals at Sanford. She is a Clinical Assistant Professor in the Department of Medicine and the Division of Rheumatology. Kinga is a Fellow Member of the American College of Rheumatology. Her clinical and teaching interests are related to rheumatology and arthritic conditions of all joints including the foot and ankle.

Kinga attended medical school at Albert Szent-Gyorgyi Medical University in Hungary. In 2001, She completed a Neurology fellowship at Millard Fillmore Hospital and an Internal Medicine residency at University at Buffalo School of Medicine and Biomedical Sciences. In 2004, Kinga completed a residency in Rheumatology at University of North Carolina Hospitals.

 Q.    What is your opinion on the Barefoot running craze? 

The barefoot movement is not new. There are two aspects to it that get somewhat confused. The benefits of contacting earth without shoes have long been recognized and have proven holistic healing benefits. The latest barefoot trend has caused running shoe brands to re-evaluate the biomechanical and design features in running shoes.

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Running without shoes strengthens the intrinsic muscles of the feet and lower anatomy; however, if performed on other than soft grass or a sandy beach has obvious topical injury risks. The whole medical podiatry profession is unanimous on the injury risk aspect.

Finally, the running shoe community, from biomechanists to shoe designers and athletes, has started to realize that most elite runners land on the forefoot area of their shoes – a long recognized fact in the running community but infrequently acknowledged in shoe design. Because 80% of runners land on the heel portion of the shoe, they require adequate cushioning, especially on hard, flat surfaces. The minimalist movement in the shoe industry now offers models with less heel lift and cushion for forefoot strikers.

Q.    Do you feel that the absence of shoes can stimulate healing?

Yes, in addition to strengthening the muscles in the feet, direct contact with earth (or Earthing) allows a two-way flow of electromagnetism from the ground to the body through the feet (electron transfer) and an equalization of electrical potential from the body to the earth (ESD). There are proven cases in which direct earth contact stimulates healing both externally and internally. For more information, see Clint Ober’s book, Earthing – the most important health discovery ever?

Q.    What are the most important features of barefoot shoes for someone who wants to try barefoot running?  

Unless there is specific forefoot technology as in Newton running shoes, there are no features other than weight reduction in so called “barefoot shoes.” The whole idea of barefoot shoes is to assist the natural forefoot striker in his or her natural gait pattern and to attempt to re-educate the heel striker to change their natural pattern. This is a very arduous and unnatural process affecting the body’s center of gravity (COG). All runners will default to their natural gait pattern as they tire. Studying graphs of Ground Reaction Forces, forefoot strikers utilize the full plantar surface and Achilles tendon to absorb shock on landing, whereas heel strikers attenuate more shock through the skeletal system of the body.

Q.    What is your opinion of the special features that the ground relays to the foot?  

Without shoes, there are two major benefits of running barefoot (on grass or sand). One is the electromagnetic contact with earth, and the other is the tactile stimulation that tends to force the runner to shift his or her COG to a more upright posture, thus encouraging forefoot strike, which some call sensory preprioception. The second point only relates to running, which begs the question, why is the shoe industry trying to market the barefoot movement as a new trend in footwear? A barefoot shoe is simply a low profile, thin-soled shoe. Nothing new about that.

Q.    If you don’t mind sharing, what are you working on right now?

What is really new is the advent of earthing or grounding the body electro-magnetically through shoes. This is a paradigm shift in footwear that has health and physiological improvement benefits and even introduces two new sciences to footwear – Geophysics and Biophysics. The biomechanical era that has influenced performance footwear for the past 40 years is now everyday science. Time for the shoe industry to explore new sciences for the 21st Century.

Mel Cheskin MBS., C.Ped. is originally from England. He is a former British Olympic runner, USTA Tournament Tennis player Level 5.0) and USGA Member (Golf). Mel attended the University of Colorado at Boulder, CO., The School of Podiatric Medicine at Temple University in Philadelphia, PA and Ars Sutoria Shoe Design College in Milan, Italy. As author of “The Complete Handbook of Athletic Footwear” and technical / medical writer for Podiatry Management, Current Pedorthics, World Footwear, Runner’s World and World Sports Activewear magazines, Mel is one of the most experienced shoe professionals in the Footwear and Pedorthic fields. In his career as a Designer and Consultant, Mel has worked for Nike (Cole-Haan), Adidas, Puma, Reebok, Brooks, Bata and Spenco Medical Corp. Mel is a Licensed Pedorthist in South Florida, residing in Boca Raton. Regarded as one of the world’s most experienced specialized shoe experts, Mel Cheskin has worked with Prof. Barry Bates (University of Oregon), Prof. Thom McMohan (Harvard), William Rossi DPM, Kel Sherkin DPM, James G. Clough DPM and Ray M. Fredericksen M.S.(Biomechanics). Mel is also a member of the Bioelectromagnetic Society in Frederick, MD. and Associate member of the American Academy of Podiatric Sports Medicine.

Obesity and foot pain

Foot pain is a rising epidemic. Present statistics indicate that at some point in time, 85 percent of Americans will have some kind of foot pain that reduces their activity level. Furthermore, 65 percent of Americans are overweight and suffer from related ailments including diabetes, heart disease and hypertension. The relationship, however, between obesity and foot health is not receiving due attention.

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In fact, a recent survey suggests that obesity is an important contributing cause of major musculoskeletal problems, in particular with the feet and ankles. In a group of people classified as overweight (average BMI of 27.9 kg/m2), there was a much higher incidence of foot and ankle pain including tendon inflammation, heel pain and arthritis of the hindfoot. Overweight people were also found to walk differently with the arch collapsing in and the back of the heel deviating outwards (hyperpronation). Pressure under the front of the foot is also increased and may cause pain in the ball of the foot and metatarsalgia.

Obesity is also linked to a higher incidence of type 2 diabetes. This further compounds the incidence of foot problems with serious complications including reduced sensation and ulceration of the foot.

With processed, heavy foods playing such a large part in many of our diets, any reduction in the amount of physical activity will have some detrimental effect on the ability to maintain a healthy weight. And, once the weight is gained, factors such as a sedentary lifestyle (e.g. watching television, sitting at a computer) aggravate the situation.

Imagine trying to lose weight – i.e. burning 3,500 calories more than you consume for just one pound of loss – when your feet hurt and you cannot even walk.

Double Edged Sword  

Walking an extra 2,000 steps each day may be equivalent to burning 100 extra calories and losing ten pounds in a year. Unfortunately, when an individual suffers from foot pain, it is much harder to engage in an exercise program to lose weight. Overweight individuals who have difficulty walking require extra help treating the symptoms. Patricia Pande, Physical Therapist and Fitness Trainer, underscores the need to maintain a healthy weight. “The single most challenging part of my job is to get people with foot pain mobile enough to increase their activity level and to burn enough calories to reduce the load they are carrying on their feet.”

First and foremost, appropriate shoe, orthotic and/or insert selection should be done before starting a walking program. People with diabetes require more assistance with extra depth footwear and inserts that absorb shock and distribute forces.

Since diet and exercise may ward off the effects of arthritis and help unload the feet, it is important to find a trainer or a gym that specializes in post rehab fitness or has some medical consultation available.

In many cases when excess weight poses a serious problem, Pat needs to be “extremely creative in designing programs that burn calories and that reduce undue strain on feet.” Often, Pat adapts traditional weight bearing physical therapy programs to accommodate tissue healing while increasing cardiac output and caloric burn. Doing steps or walking on an incline can result in loads of four to six times the body weight across painful foot joints. An exercise program must be designed that protects these joints, strengthens your foot muscles and ensures that you get a combination of low load cardiovascular exercises without putting biomechanical stress on the joints.

The challenge is not easy but it is not impossible to overcome. For more information, contact Pat at patpande@footcentriconline.com or check out her courses here.

Catching up with Paul Shapiro, MD

Q.    How much foot pain do you see in your practice as a physical medicine doctor?

I see numerous people with foot pain and arthritis, soft tissue injuries and chronic pain and strains.

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Q.    In your opinion, does prolotherapy help foot pain? Are there some conditions that respond better than others?

Yes and yes. I think prolotherapy helps foot pain in general, but it is most effective in cases of:

• Chronic ankle sprains
• Early bunions and arthritis/degenerative change
• Tarsometatarsal joints and Lisfranc joints
• Other soft tissue injuries, in particular Achilles tendinopathies

Q.    Are you having success in your practice using prolotherapy for foot pain?

Yes, I am seeing good results, though I do not use prolotherapy as the first line of treatment. Rather, prolotherapy is used if other treatments do not work as well as first hoped. The results are usually better when you combine them with overlapping therapy such as physical therapy, footwear modifications and orthoses or inserts.

Q. Have you seen any adverse effects with this type of treatment?

I have not seen any serious adverse effects with prolotherapy. It is possible to get a little swelling after the injections, but it is not a worrisome side effect and is easily treated with ice and rest.

Board certified in P.M.&R., Paul Shapiro has been in private practice in a multi-physician P.M.&R. group practice since 1985. Previously, he oversaw the Orthotics and Prosthetics Clinic in the Rehabilitation Medicine Department at the Ann Arbor (Michigan) Veteran’s Administration Center Hospital. Paul’s medical and teaching interests include medical acupuncture, manual therapies and prolotherapy.

Paul received his M.D. degree from Michigan State University College of Human Medicine and completed a residency program in Physical Medicine and Rehabilitation at the University of Michigan Medical Systems.