Sports podiatry is entering a new phase. Here's a step-by-step analysis of the fresh approach
Traditionally the role of the podiatrist in sports medicine has been to prescribe corrective orthotics, which are inserts for the athlete's shoes to control the motion of the foot. A common example is an orthotic which angles the rearfoot outwards (inverts the heelbone) to control any excess pronation movement during walking and running.
Rearfoot motion problems, particularly over-pronation, have been linked with many common injuries such as Achilles tendinitis, plantar fasciitis and anterior knee pain. The research available into the effectiveness of orthotic devices suggests that they can help solve injury problems, with a success rate of around 70-80%.
More active rehab needed
The success of orthotics has led many podiatrists into specialising in sports medicine, where they can examine the athlete and prescribe an orthotic to correct any foot biomechanical problems. Justin Blake (of the Bodyfactor Rehabilitation Clinic in London), is one such sports podiatry specialist; however, his belief is that podiatry can go beyond simply giving orthotics to each client and should incorporate more active rehabilitation methods to help tackle the causes of the biomechanical problems. As Justin says, 'If the only tool in the box is a hammer, then you only see nails.' He believes that podiatry should look at many ways to improve a patient's foot mechanics as well as using orthotics, which simply place the foot in a new position but do nothing to help improve lower leg muscle function or joint alignment.
Modern physiotherapy has moved on from ultrasound and massage, which address the symptoms, to helping patients improve the dynamic control of the joints and function of the muscles, which look at the causes of injury. Podiatry is also starting to adopt this approach and this article will outline the Bodyfactor paradigm as an example of a modern way of treating a patient.
This involves testing the foot and ankle with the subject lying down, looking at the rearfoot and forefoot alignment and the amount of ankle dorsiflexion. The patient is then examined in a standing position to determine how the foot and lower leg are aligned during weight bearing. These are the basic podiatry tests to help diagnose any problems.
Additionally, the patient's posture, stability and flexibility in the leg, hips and back are assessed. This information helps the podiatrist to understand more about the patient than simply what is occurring in the feet. For example, a lordotic posture with the pelvis tilted forward causes an inward rotation of the knees which in turn inwardly rotates the tibia which promotes an everted ankle (pronated position). Additionally, tight calf muscles are related to over-pronation, as the foot compensates for a lack of dorsiflexion range by rolling inwards.
Manual muscle testing
The podiatrist tests the strength of the four main ankle movements - plantar flexion, dorsiflexion, eversion and inversion - with the use of manual muscle tests. The purpose is to subjectively assess the ability of the ankle joint to resist external forces and control eccentric motion. For example, one contributory factor to excess pronation could be weak evertor muscles. When the foot strikes the ground it rolls inwards; this is called ankle inversion or pronation. It is the ankle evertor muscles that act eccentrically against gravity to control this pronation movement, and if these are weak the pronation movement may be too fast or too great.
The patient's biomechanics in motion are analysed. Markers are placed on the rear of the heel and the Achilles to help determine the range of motion of the rearfoot. Initially, this simply involves watching the foot motion during walking on the floor, with the podiatrist making subjective judgments about the gait pattern. The patient's movement, walking and running is then analysed on a treadmill with a digital video camera from the rear and side view. The digital camera allows for freeze-frame analysis of specific points in the gait cycle.
The podiatrist is particularly interested in the degree of supination of the foot at contact, the degree of pronation during stance, the timing of pronation and the degree of re-supination at toe off. For example, the foot is meant to pronate to absorb the energy of landing. This pronation is normal and necessary, but if the foot stays fully pronated throughout the stance phase and does not re-supinate, then the foot is less rigid during toe off and the adjacent structures have to work harder to compensate, thus increasing overuse injury risks.
The podiatrist is also analysing the degree of pelvic drop on the free side during swing phase and the postural alignment during running and walking. For example, if there is an obvious amount of pelvic drop this can cause internal rotation of the knee and promote pronation.
If necessary, the podiatrist also analyses the motion during a sports specific movement, eg, moving to hit a forehand in tennis, to check for any problems in these non-linear positions.
From the results of this comprehensive analysis the podiatrist can paint a picture of the causes of the injury problems. These causes are usually a combination of factors, such as poor flexibility, strength and mis-alignment of the foot or lower leg. The main purpose of an orthotic is to place the foot in a position in which it can move naturally and remain stable. Therefore, the orthotic tackles only the mis-alignment problems. The flexibility, strength and core stability deficiencies discussed above, which can all contribute to poor foot mechanics, will not be improved by prescribing orthotics alone. These aspects require an active rehabilitation programme which the patient must follow. The components of a typical programme could include the following elements:
Flexibility exercises: stretches for the gastrocnemius, soleus and any other leg, hip or back muscles which are found to be tight.
Strength exercises: dorsiflexion, plantar flexion, eversion and inversion exercises using the resistance bands and closed chain ankle plantar flexion exercises standing, with static inversion and eversion.
Core stability exercises: abdominal hollowing to improve the lumbar control and posture, standing pelvic tilting to improve the gluteals' ability to keep the pelvis level during the swing phase.
The podiatrist also helps the patient buy the correct training shoes, recommending the shoes that suit his or her particular foot type and problem, and checking the effective-ness of the shoe using the digital camera.
Customising the prescription
In this way, by looking to improve muscle function, posture, stability and get the footwear right, the podiatrist can do much to improve foot mechanics without prescribing orthotics. This allows him or her to start with a temporary and soft orthotic for many of their patients, in the hope that this will be sufficient to solve the injury problem. In cases where the problems are severe, then a cast orthotic with a hard material is prescribed, but this should not be a standard policy. Modern podiatry must recognise the individual patient's needs and customise the prescription accordingly. For instance, a mere 60% of Justin Blake's patients receive orthotics, ranging from soft inserts to hard casts, which means that each patient gets the solution that is considered best for his or her particular set of problems.
The condensed version and the bottom line
Modern podiatry looks at the causes of the injury and foot mechanics as well as prescribing orthotics to improve the foot alignment.
By including active rehabilita-tion in the prescription, the podiatrist can help the patient to improve his or her foot mechanics, thus helping prevent further injuries.
The integrated approach, which includes finding the correct shoe, enables the podiatrist to offer a custom solution to each patient and allows them to vary the type of orthotic which is prescribed.
The practical advice for therapists and fitness trainers is this: before sending off your clients for orthotics, ensure that you have corrected any postural problems, improved core stability, strengthened the ankle muscles and increased the flexibility of the calf muscles. If you don't do these things first, the money spent on orthotics may be wasted.