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PES PLANUS - THE PROBLEM---

Pes Planus simply means, flat feet. There are many reasons for this condition, the first of which is heredity. Blacks, Native Americans, Swedish, Northern Italians, Black Forest Germans and others have a natural tendency to be flat footed. Many have this condition and never have any problems of any kind.

However, others will have this condition created. Years in soft, unsupportive shoes on hard surfaces, injury, pregnancy, or other factors. This often leads to other problems that will be presented on the following pages.

The arch in the foot is caused by a broad band of fibrous connective tissue, called the longitudinal ligament. A ligament is nothing more than connective tissue that connects bone to bone. The longitudinal ligament connects the metatarsal phalangeal joints to the os calcis or heel bone. Like a string on a bow, they hold the two ends together and create an arch. This arch is a shock absorption structure and it also helps to maintain all the tarsals in proper erect anatomic position. As this arch decreases, impact from the concrete becomes worse.

When the arch ligament stretches or tears, the arch falls. If it falls far enough, the tarsals may begin to shift to the inside or create pronation or a valgus (greater than 90 degree erect) position at the ankle. This can cause problems in the origin area, (the metatarsals) or in the heel. It also may cause pressure on the medial (inner) knee and perhaps the hip and back. It is like pulling the string on a marionette too tight, the result is a kinked mass on one side. The human body is much the same, put too much tension on major muscle groups and the joints kink and yell back.

THE SYMPTOMS

As the ankle shifts inside, you may notice a gap between the foot and the outside wall of slip on shoes. If bad enough, even tie shoes will show this shift. The farther the shift. the more problems that are created.

Pronation or valgus is rated as first, second and third degree, just like burns. First degree is a small amount of medial displacement, usually no pain or chronic problems. You may have a gap in some of your shoes, some extra callous formations (usually at the ball of the foot or out side of the heel), and you may turn your shoes and wear down the outside edge of your heel.

Second degree pronation is simply more rotation to the midline. Some minor leg aches at night, just after you go to sleep may occur. Shoes do turn, and heel wear is worse. Some may complain of arch pain or pressure in the inner knee.

Third degree pronation is a true valgus condition. The rotation is very evident. In some, the talus bones make such a shift to the inside, that the navicular is actually pushed out of position and can be readily seen. In these persons, the shift is great enough that they often look like they have two ankles. Your ankle bone is actually part of your descending tibia and fibula leg bones. They are large areas of muscle attachment that hold your foot on to your leg. The second bone showing is the displaced navicular. This is caused when the heel bone pivots to the inside, allowing the talus above to also shift medial and down, forcing out the navicular.

VALGUS OR PRONATION a Common Result

SOLUTIONS

For flat feet, pes planus, just wear good solid shoes that do not bend in the arch. If you are pronating with it, look for solid heel counters in shoes to help hold you erect. If in pain, consult a doctor. They usually start with a stronger shoe, and then may add a pre-fab arch support or go directly to a custom arch support.

Generally a soft arch support in a soft shoe is a waste of time and money. The will both bend through the arch and continue to break down the arch. Historically, soft arch supports in hard or orthopaedic shoes, and hard arch supports in soft shoes. Shoes with little or no heel counter usually will not hold you over the arch support. The result of this, is many will slide off the arch support out through the side of the shoe. In severe pronation, many will pronate over the arch support through the side of the shoe. So many arch supports will not give full correction to begin with, and may not do much at all if the patient is sliding or pronating through the sides of weak shoes.

Sometimes thicker and bulkier arch supports will be made by the doctor. These usually do not fit in conventional shoes at all. They require deeper shoes. Shoes that can accommodate the volume of the foot and the volume of the arch support. Putting these arch supports in conventional shoes, will pinch the instep and even cause pain. A secondary problem is that the foot is jammed down on the arch support, and this will make the arch support hurt the arch and cause the patient to either not wear the arch support or return to have the arch support cut down.

Another chronic problem with arch supports is heel slip. Most arch supports come up behind the heel. The foot sits in the cup of the arch support heel. The wall of the arch support, holds the heel slightly forward and therefore creates a small air space the thickness of the arch support between the foot and the heel of the shoe. This air space causes some slippage in the heel. Another related problems is that all shoes have a locking point in the heel of the shoe for the heel bone to fit in and lock. When the thickness of the arch support raises the foot, it moves out of this built in shoe locking mechanism. The thicker the arch support, the more the foot is raised out of the shoe. So there you stand in a pocket of air, 1/4 to 1/2 inch above the normal position a foot would normally rest and your instep is bound, the arch hurts and perhaps the shoe is now too short too! This is the worse case, and usually only found with women. Women's shoes are often shallower, more open and have less support.

Solutions may come from a cross trainer tennis shoe in the proper width, that has a solid arch and heel counter. They do exist, but in only two or three companies and even then you have to check out each shoe, as they have price lines, and some are as bad as the cheap imports. Walking shoes will often hold arch supports, but again, make sure they have a steel shank and a hard heel counter. Good walking shoes will have these features and most will not. Name brands are no guarantee of quality. Some companies spend more on advertising than quality components. Orthopaedic shoes like Barefoot Freedom and P W Minor make orthopaedic shoes with in-depth features. By this I mean that they come with a full soft orthotic innersole. The heel locking mechanisms are higher in these shoes, so with the innersole out and a custom arch support in, the heel is still in the correct area to lock. These shoes also have higher and wider steel shanks, they will not bend or break down in the arch and resist twisting. They also have orthopaedic heel counters which extend down to just before the ball of the foot on the inside and about 3/4 this length on the outside. This locks you over the arch support, and helps you stand erect or what the doctors call anatomic position. The toe boxes are also about 1/4 inch deeper to allow room for your toes and the thickness of an arch support. These shoes are also used for hammer toes, bunions, arthritis and other problems. Whether you try a tennis shoe, walking shoe, conventional shoe or orthopaedic shoe with an arch support, look for padded collars. They expand with air had help the top of the shoe make more contact with your foot. This contact will reduce, not stop, heel slip with arch supports.

Ignored, pes planus and valgus can lead to worse problems. Please proceed to the forward link.

PLANTAR FACIATIS ------------------------------------------- ----------------------------------------------

The longitudinal ligament is a broad fibrous tendon like tissue that extends from the heel bone forward to the base of the toes ({origin} - os calcis or calcaneum to the {insertion} - metatarsal phalangeal joint).

SYMPTOMS are pain on the plantar or bottom part of the foot between the ball of the foot and the heel. Pain may be worse in the mornings when you take your first steps and may subside with prolonged walking. Pain is usually worse when you first get up, first walk or begin activity, then may subside over the time of activity. This kind of pain is usually found in people with higher natural arches, a more rigid the foot, flat feet or pronation. The more rigid or flexible from normal the more prone to injury. Rigid feet are more prone to tears. Pronated feet more prone to excessive stretches of the ligament. The extreme motion and shifts can cause the excessive stretch to cause the inflammation and pain.

Main cause is a sudden increase in activity, worn out shoes, shoes without a steel shank, shoes that are turned over, have no heel counters or sometimes very stiff shoes like platforms and clogs When the longitudinal ligament itself gets stretched too far or torn through injury, it may become inflamed. All the soft tissue around the ligament may also become involved. The end result is called Plantar Faciitis. A condition of extreme pain on the bottom of your foot in the arch area.

SOLUTIONS are usually fairly simple. Rest is best, but may take months to heal. Some foot exercises may help by strengthening the surrounding tissues to help support the foot structures. Shoes and orthotics are the most common tools used. Weak arched shoes are replaced with shoes with steel shanks, or double steel shanks. Double steel shanks are are higher, wider and contoured for right and left feet. Solid heel counters or extended orthopaedic heel counters help by maintaining better alignment and preventing some pronation. Then it is a matter of trial and error. Scaphoid pads, pre-fab arch supports or custom arch supports may be used by the patient or the doctor to take the stress off the foot. The way is works is the support creates an artificial arch and shortens the distance of the stretch. They also maintain the present arch and thus take pressure off the tissue. Over time, the soft tissue and ligament heals. It can take many months to a year for the ligament to heal if it has been torn. Less time if it is just irritated. The real problem is that the skeletal conditions that led to the problem have not been corrected and the tissue has been weakened, so it is now easier to re-injure the foot.

HEEL PAIN, SPURS ---------------------------------------------- -

SYMPTOMS

Related to plantar fasciitis is a heel pain or spur. The longitudinal ligament has it's origin on the plantar anterior surface of the calcaneum (heel) bone. When the ligament is stretched too far, it pulls on this attachment area. It can become inflamed and sore. If the problem persist, the body may try to heal it by reinforcing the attachment area by adding bone. This is just as the body heals a fractured bone. A hormone is secreted that is drawn to the inflammation site. Chemically this hormone draws calcium out of the blood stream and deposits it in layers over time to the injured area. If the process continues long enough a spur of bone may be laid down. Because the bone is thicker and harder, it irritates easier the through constant impact of walking. This causes more irritation, inflammation and draws more hormone which pulls more calcium which lays down more bone which irritates more etc. Around and around you go, each cycle slightly worse.

SOLUTIONS

Shoes that do not bend in the arch, hard heel counters to hold you straighter, cushion innersoles, cushion heel and sole materials like vibram, felt U's or heel pads with cut outs to suspend the irritated site in air and force the foot to bear weight on the outer edges of the bone. Custom orthotics with various cushion and weight transfer systems, and other build ups. Even raising the heel height to bear more weight on the ball of the foot may be used. Again it is trial and error. What works best for one person may not work at all on another person. You start with the shoe and go from there. Looking for the least expensive and most effective solution.

Since the problem took place over a long period, it will also heal over a long period. Tendons and ligaments have poor blood supplies and do not heal fast once injured. The good news is that if you can take all the pressure off, the body does have a memory and often will re-absorb the extra bone that was laid on over time. In extreme cases, a surgeon may have to remove the spur, but most doctors are extremely reluctant to do any surgery, preferring to use shoes and arch supports to manage the problem. Surgery in the area is very dangerous as it is a weight bearing area and if you have the metabolism to cause spurs, irritating the site through surgery may cause more and worse spur formations. Most doctors will not elect to ever do surgery on this area.

Sometimes the doctors may use shots of anti-inflammatory drugs to attempt to stop the inflammation pain cycle. These do not cure the problem, but treats the symptoms. If they can stop the inflammation, the risk of spurs is lessened. However, the foot structure that caused the problem in the first place has not been changed, so once the drugs wear off, the pain problem often comes right back So the final choices for resolution are strong shoes with lots of cushion, perhaps arch supports and time.

BUNIONS ---------------------------------------------------------------------------------------------------

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SYMPTOMS

Bunions are enlargements of the bone at the joints. They form in much the same was as heel spurs. Causes may vary. Shoes that are too short or too narrow that pinch and cause stress to the joints. The bone then inflames and starts the cycle of putting on additional layers of bone to mend the stress area (like a fracture). Pointed toe shoes that squeeze the toes and stress on the joints and high heels that shift the weight to the ball of the foot are other causes. Even nylon hose can contribute and cause the problem. As the day progresses, the nylon continues to draw on the toes and eventually they get tired of the struggle and bunch up within the nylon. At night after being held in this jelly mould, they are in a ball. Multiply the day by thirty years and you eventually train the toes to bunch and the constant stress causes the joints to enlarge, become inflamed and lay on layer of bone.

Severe pronation is the main cause. These people tend to toe out and roll in at the ankles. At heel strike they hit the outside of the heel, roll into foot flat and as they continue to roll forward, tend to drive their first metatarsal phalangeal joint out through the edge of the shoe into the concrete. This causes excessive stress and inflammation. As the inflammation progresses, the body puts on more bone, this irritates easier and causes more inflammation and puts on yet more bone. The enlarged bone presses on the side of the shoes, presses back against the joint causing more irritation. Each year the process repeats and the joint becomes larger until the toe begins to swing from its natural access and interferes with the other toes. Overlapping toes are often the result with associated arthritis. Symptoms are enlarged joints, toes that deviate and pain.

SOLUTIONS

Shoes with oblique toes (straighter last foot shaped), with support features that help prevent pronation, that have in - depth features. Avoid any shoes with rough seams against the joints or have several layers sewn together at the point of the bunion. Avoid taper toes, high heels, shallow or too narrow shoes. You want the foot to be held as straight as possible and the forefoot should be like you are barefoot. Some walking shoes work, but again, do not buy any shoes that, with pressure from your thumb or fingers, bend in the arch. Shoes without steel shanks can twist and allow the foot to put more stress on the first metatarsal joint.

Generally it is a poor decision to go too wide. When you go too wide, the instep and heel do not fit properly and the foot can slide back and forth. The motion will cause friction and more irritation and stress to the joint. It is usually better to go to shoes that are very wide in the forefoot, but correct in the instep and heel. This is why oblique toe shoes work so well. They may not be pretty and Cinderella would not wear them to the ball, but they are functional. You can work and walk better longer in them. In some cases the joint is so enlarged that no shoe is wide enough. In this case, you are normally better to fit the shoe correctly and use a tool called a ball stretch to make a pocket out through the side of the shoe for the bunion. For the shoe to fit correctly, the bunion should be at the widest part of the shoe, the ties should be parallel and and the heel counter should support the foot. The factories make shoes in standard length and width increments. The size on the box may not be the shoe's true size. So watch the ball of the foot position and how it ties. Since the factory did not know that you needed an attic or side room, they did not put one in. By the way, your old shoes are all stretched out for the deformity. This took body heat, perspiration and time for the leather to mould around the problem. In new shoes, the pocket does not exist, so there will be more pressure until the pocket forms. If the pressure is uncomfortable, you can relieve it by having a shoe repair or shoe store stretch a pocket in the necessary area. This will start your custom pocket and relieve the pressure. In a few days, the new pocket will be like the one in the old shoes and you will not notice the difference.

You will notice I only discussed tie oxfords. The reason is that bunions require softer fits. Open shoes tend to get sloppy and loose through time. You have never owner a pump, flat or loafer that did not stretch out and get loose. This in spite of the fact that they are made shallower, more tapered and tighter in the instep than tie oxfords. Since there is less toe room, bunions will put you into ties for daily wear. Dress shoes because they are more tapered and shallower may require you to go wider to accommodate the bunion. These will also require more stretching and probably will still be snug. Sitting shoes to be worn from the house to the car, into the restaurant, theatre, church or event and then kicked off until it is time to go back to the car for the ride home. They will not be for doing the mall, vacations or long term walking or being on your feet.

With proper shoes, arch supports and other means, you may be able to live comfortably without surgery. Surgical solutions include removing the bone, removing the joint capsule and sometimes pinning the joint. Most doctors will not do surgery if the problem can be controlled with shoes or shoes and arch supports.

From our experience surgery is the last recourse. With today's modern techniques the results are usually good, however there is always a risk. The same doctor with the same staff, in the same hospital doing the same surgery the same day on ten different patients will get different results. Six will be cured. Two close to cured, one slightly better and one the same or worse. Individual metabolisms affect the results.

If you have surgery, do not go back and put on your old shoes. They were stretched out for your deformity and if you put your foot into a jelly mould with a built in problem, you will heal with the built in problem. Best results are in the Orthopaedic oblique toes. These shoes hold you straight and allow the forefoot to be barefoot, thus encouraging you to heal straight. Bone heals in about six weeks, muscles in three months, tendons in 9 to 18 months depending on where they are, yellow ligaments 9 months and white ligaments a year. In surgery, all these things were cut, stretched, and sewn. As a general rule, you will go into shoes again in about 6 weeks after surgery. The swelling will be down to close to normal in about three to six months. Pain will be gone in about two to three months. Healing of all the foot structures can take up to a year and a half depending on you, the surgery and how much trauma the foot received.

Since medicine is an art and not a science and the results can not be guaranteed, most doctors will attempt to use shoes and arch supports to treat the problem. Surgery will be used as a last resort where the problem is so painful that the patient can not function with a normal life and shoes and arch supports have been unable to give relief.

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RELATED ARTICLE - ARTHRITIS