Podiatry and orthotics

People often ask us questions about orthotics, gait and foot conditions, and we may refer them to a podiatrist. We spoke to Denzil Trebilcock at The Gait and Posture Centre in London about podiatry, ‘insoles’, minimalist running shoes and the most common problems he sees.

Anjulie: Most people will associate a podiatrist with feet and ‘insoles’. How would you describe your profession and what (if any) are common misconceptions about podiatry?

Denzil Trebilcock: From a public perspective the most common source of confusion has always been the difference between podiatry and chiropody. Nowadays there is no difference between the two terms and our governing body is transitioning to the sole use of podiatry. This brings us in line with other countries throughout the world who have always used podiatry.

As a discipline, podiatry looks at the treatment of all conditions and diseases associated with the foot and ankle. This ranges from biomechanical injuries associated with overwork, stress-related reactions, ruptures and tears to the soft tissue structures, but also disorders of the nails and skin over the foot and ankle.

As such we undertake extensive training in dermatology, pharmacology and physiology as we must be prepared to identify potentially threatening lesions and treat highly vulnerable individuals with complex underlying medical conditions such as diabetes and rheumatoid arthritis.

From a biomechanical perspective we look at how the dynamic movement of the lower limb is affected by structural alignment in the skeleton, and use a combination of intrinsic strengthening exercises of the feet as well as insoles, silicone toe props and orthotics to help correct the functional movements and loading of the feet through the gait cycle.

Anjulie: What sorts of problems do you come across most often as a podiatrist?

Denzil Trebilcock: As I mentioned above, the work we carry out can be divided into two main sections: biomechanical work and podiatric medicine. Each has common problems, but occasionally you find that a problem from one section may cause a problem in the other section.

Common problems with biomechanics would be plantar fasciitis, sesamoiditis, synovitis, neuromas, medial tibial stress syndrome, posterior tibial tendon dysfunction, hallux valgus and hallux limitus. We are also regularly requested to analyse individuals lower limb mechanics and gait if they have chronic problems associated with hypermobility, calf strains, lower back pain, trochanteric bursitis or other structural imbalances that other practitioners might have noticed.

From a podiatric medicine point of view, we see skin issues associated with callus formation, soft and hard corns and verrucas, and of course conditions affecting the nails, including ingrowing toenails. We also monitor vulnerable patients who have diabetes, rheumatoid arthritis or who are receiving immunosuppressive therapies. Sadly, the feet can be a portal of entry for infection, so vulnerable individuals regularly require podiatric care.

Anjulie: Do you receive many referrals from physiotherapists? What other professions do you receive referrals from? Do people also often self-refer?

Denzil Trebilcock: Over the years the practice has built up many solid relationships with a wide range of referrers from different disciplines, including physiotherapists, orthopaedic surgeons, rheumatologists, GPs, paediatricians, osteopaths, Pilates instructors, yoga teachers and dance teachers.

We also see people on the recommendation of previous patients. So, we must be doing something right! We do see a lot of people who come because of internet searches on foot pain or foot problems, and with my links to the Royal Ballet Company they feel confident they are seeing someone with a lot of experience treating lower limb conditions.

Anjulie: Some people say that modern footwear is the cause of many foot-related problems, such as bunions. Would you agree?

Denzil Trebilcock: There is no question that footwear has links to foot-related and lower limb problems, you need only to spend a brief period of time in an ill-fitting pair of shoes to realise how quickly problems can set in. But holding footwear alone responsible for these foot problems is too simple and fails to acknowledge the multiple factors that co-exist for that problem to form. Studies have clearly shown that the same foot-related problems exist in unshod populations as they do in shod populations, so footwear cannot be the sole culprit.

Where footwear is implicated in foot-related problems there are two broad areas that need to be considered:

1. The fit – how the size and shape of the shoes compares to the feet;
2. The appropriateness of the footwear for the situation.

On their own, these two things sound easy to address, but in reality the psychological and emotional factors as well as the pressures we place on ourselves and others to conform makes this a far more complicated decision process. Unfortunately, we often see these simple considerations being overlooked at the expense of the wellbeing of our feet.

We also need to consider that people are susceptible to ill-informed advice, be it from clever footwear marketing or well-meaning people hoping to provide a quick fix for someone without fully appreciating the reasons behind the original problem. As a result, people find themselves following a pathway that may not necessarily be right for them, and we see the continued belief that footwear is to blame.

Anjulie: What is your view on the barefoot/minimalist technology that also stems from podiatric medicine? Do you think that this contradicts the use of orthotics?

Denzil Trebilcock: The concept of barefoot core strength is one that I strongly believe in. It is a fundamental truth that to support the full weight of your body, to provide a sturdy base with which to propel yourself from and yet be able to adapt to any surface terrain and be stable on your feet means you must have both intrinsic foot muscle strength and good proprioception.

I see the amazing benefits of this constantly through my work with the Royal Ballet Company. The years of diligent work that the dancers have put in, the hours of classes and conditioning allow them to perform the most amazing feats. However, I have also seen that this alone does not protect you from the ravages of injury or chronic overuse. I mentioned above that unshod populations still experience the same issues as shod populations. They clearly have strong intrinsic muscle strength, but that alone is not sufficient to eradicate the problems. There are clearly joint structural alignment issues or skeletal morphologies that muscle strengthening just will not resolve.

When we talk about barefoot /minimalist technologies, we often refer to footwear styles and specifically to running footwear. Now, as I have mentioned above there is plenty of evidence to support barefoot core strength and how it can be a great benefit, but I fear that the marketing overlords have taken this kernel of truth and produced an entire range of footwear that they say will sort all your problems – one size fits all and is a must for everyone! At this point the marketing has overtaken the evidence and it becomes completely inappropriate.

It makes sense that a combined pathway is adopted, and it is this considered approach that I take with my patients. Where extra controlled alignment is required, I use orthoses; where stabilisation and balance are required, I advise core foot strengthening.

The other thing to remember is that a good orthotic encourages normal muscular activation and so if weakness exists then strengthening is needed. As a result, I strongly believe the two should co-exist in a treatment environment.

Anjulie: How would you describe the function of orthotics? What other equipment or devices do you provide for foot-related problems?

Denzil Trebilcock: When discussing the function of orthotics, one needs to remember that they only work when the foot is in contact with the ground. During this period there are a lot of mini events that occur, any one of which may cause problems should it be mis-timed.

Loading starts from initial contact, usually heel strike, through to mid stance and finally on to the propulsive phase where the heel lifts off the ground and only a minimal surface area of the foot is still in contact with the ground. The amount of time that the foot is therefore in contact with the ground is fractional, but in that time the foot has transitioned from shock absorber to a mobile surface adapter to a single limb load bearer and finally to a rigid lever to propel the foot off the ground. A constant cycle of muscular control, structural alignment and power control.

This is a key to remember when talking about the function of an orthotic, because a lot of people believe that it will create weakness within the foot. But as you can see from above, this is simply not possible as the foot still operates as a dynamic system but within normal parameters, prevented from going beyond the normal range of movement by the orthotic.

Another functional aspect to consider with orthotics is that they help to create elevation under the foot. This elevation can be placed wherever it is required, or only on one side to create an artificial balance for a leg that may be shorter than the other. This in turn assists with the positioning of the pelvis or loading through the hips and knees.

Whilst orthotics play a particularly significant role in our treatment, we also use a combination of padding and strapping techniques to help offload the various areas of the foot. We use handmade silicone toe props that are made specifically for an individual’s toes to help either separate over-riding toes or create a system to help elevate the metatarsal heads in cases of synovitis and neuroma problems. And as I mentioned above, we advise on intrinsic foot muscle strengthening exercises.

Anjulie: Do you think orthotics can sometimes be over-prescribed?

Denzil Trebilcock: I suspect there is a high proportion of practitioners who do prescribe orthotics for the sake of any foot pain and persuade people that they require orthotics on a long-term basis without fully appreciating the cause of their problem. We always try to get to the root cause of the condition before making such a rash judgement.

From the other side of this question, I would say that there are chronic problems which cannot be resolved with the best will in the world. If strengthening and self-guided exercises are not working then providing a stabilising support system is especially important in the treatment of such conditions. Afterall, your feet are the foundations of your body and if there are imbalances at this level, then unless they are addressed problems will always creep back.

Anjulie: Do orthotics need to be worn ‘for the rest of your life’? What sort of situations may require temporary vs ‘lifetime’ orthotics?

Denzil Trebilcock: This is very much based on the individual case. The underlying issue that exists may have come about because of some acute traumatic episode and therefore you need support or cushioning for a brief period of time but have no long-term need for control.

On the other hand, if we are dealing with a condition associated with the position of the skeletal structures of your feet or legs then no matter how many hours of exercises you do, your body will always revert to its most stable collapsed position. Then you may require an orthotic for the rest of your life.

This does not necessarily mean that it must be worn 100% of the time. We often find that once the initial painful episode subsides a person usually only has to wear an orthotic for about 70% of the time as the body does not suddenly change or immediately revert to causing pain. This is particularly useful around summertime, where you may not want to wear an orthotic in a sandal or a lighter shoe.

If you are not spending a great deal of time on your feet, it really doesn’t matter. Equally if you are going to be taking part in something particularly energetic then it is wise to wear a shoe that allows you to have the orthotic in place. The general rule of thumb is to listen to your body, it will tell you if it is happy or not to forgo the use of your orthotics.

Read our article in Sebra News W2 on Why are feet so important?.