Clinical Pearls
03 President’s Message
04 T Spine to Plantar Fasciitis
- The Chain of Events
05 Summary of; The relationship between foot
motion and lumbopelvic-hip function: A review
of the literature
07
History Taking 101
08Elastic Therapeutic Tape and The Foot
Care Professional
10Forgotten Conditions: Four conditions you
may forget to consider during your Pedorthic
assessment
SUMMER 2013
14In Our Patient’s Shoes: Better Bedside Manner
for a Better Business
15Top 5 Functional Tests to Consider in Your
Pedorthic Assessment
16
PAC 2013 Symposium
17
Pedorthic Technology
20 Member Profiles
A Periodical of the Pedorthic Association of Canada
perfect
the
fit!
Introducing the...
New Apex
Rotating Display
We are excited to introduce our new
Apex Rotating Display. The unique design
is compact, efficiently holds up to 40 footwear
samples and looks great in any professional
office setting. We are confident the new
display will help you elevate your practice
image, increase sales, and improve
patient care.
Purchase your Apex Rotating Display for only
$299 and receive your next 10 pair of Apex
footwear at a 50% discount - a $300 value!
800-526-APEX | www.apexfoot.com
A Periodical of the Pedorthic Association of Canada
SUMMER 2013
President’s Message
LISA IRISH, C. Ped (C)
Summer…. Long sunny days at the cottage, reading,
swimming, sailing, sitting in Muskoka chairs on the dock with a
cold drink and good company. Not everyone’s experience this
year perhaps. Summer has been doing some rather odd things
across our great country, certainly making it memorable, if for
all the wrong reasons. In Toronto we just had a tiny taste of
the devastation that Calgary and surrounds has endured. It certainly makes other issues
pale in comparison. An interesting season indeed.
I’d say this is shaping up to be an interesting year all round for many reasons. On
a personal note, this year has brought some big changes for me. Obviously, I have
taken on the role of president of PAC, thus the missive you are now reading. Also, there
are other big events. I now have two of three kids off at university, huge shift in daily
dynamics (not to mention financial dynamics). I changed jobs, a big deal for me since I
consider myself wretchedly difficult to work with (control issues I think) and have thus
stayed self-employed for many years. God bless the people who put up with me daily. I
had my first industrial accident in over 27 years, cut my finger to the bone with an exacto
blade. Shows it’s never too late for all kinds of things.
Another big event for us was our PAC board of directors meeting in Muskoka in late
May. We had the opportunity as a new board to review our strategic plan for PAC. I
was very impressed with our new board members, as well as our existing members,
as we spent several intense days discussing the direction for PAC, our priorities and
plans for implementation. There are many issues facing us as pedorthists that require
hours of work by the board, committee members, and task force volunteers that will
shape our profession, directly affect how we operate our businesses and treat our
patients. We continue to actively explore what regulation may mean for us and are
engaged in current discussions regarding the foot care model review in Ontario, which
has implications for us all. A task force is examining what patient outcome measures
and evidence based practice means for pedorthics. We are always in close contact with
insurance providers, trying to ensure that pedorthists are well represented in insurance
policy and government programs. We are pursuing a model of pedorthic education that
will ensure consistency in training of new pedorthists.
In all we do we continue to work toward the goal of having C. Ped (C)s the most well
recognized foot care expert in Canada. It continually amazes me that not all people know
about pedorthists, because from all the experience I have had with pedorthists over a
long period of time, you are truly an amazing lot.
Publisher Information
Pedorthics Quarterly
A Periodical of the Pedorthic Association of Canada
Pedorthics Quarterly is published by:
Pedorthic Association of Canada
Suite 503 – 386 Broadway
Winnipeg, Manitoba R3C 3R6
Toll Free: 1.888.268.4404
Fax: 1.877.947.9767
Email: [email protected]
Printed by Unigraphics
Communications Committee
Chair
Amy Guest, C. Ped (C)
Vice Chair
Tavish Lahay-Decker, C. Ped (C)
Committee Members
Nancy Kelly, C. Ped Tech (C), C. Ped (C)
Matt Neufeld, C. Ped (C)
Jim Pattison, C. Ped (C)
Crystallee Ripak, C. Ped (C)
Michael Ryan, C. Ped (C), PhD
Alex Whyte, C. Ped (C)
Subscriptions: $199 per year in Canada
All articles published in Pedorthics Quarterly
are the property of the Pedorthic Association of
Canada. Copyright ©2013 Pedorthics Canada All
rights reserved. Reproduction in whole or in part
is permitted only with the prior written consent
of the Pedorthic Association of Canada. Address
all requests to the PAC office. Trademarks and
Registered. Trademarks used in this publication
are the property of their respective owners and are
used only for the purpose of information.
Help Us Be Green!
PQ Feedback
We would appreciate your feedback on the PQ and its articles. Your ideas and thoughts are
important to us. Let us know what you think.
E-mail your letter (referencing the article title and PQ edition) to: [email protected]. Please
include ‘PQ - Letter to the Editor’ in the subject line.
PAC also invites you to comment about articles in the PQ via our Linked-In page.
If you are interested in contributing articles for the PQ, contact [email protected].
If you would like to receive Pedorthics Quarterly
electronically instead of the paper version,
contact the PAC office at [email protected].
To those of you who are already receiving the
online version, thank you for helping us be
green!
Did you know you can read past issues of the
Pedorthic Association of Canada quarterly
publication online? Go to www.pedorthic.ca
and log in to your member record.
3
T Spine to Plantar Fasciitis The Chain of Events
Rileigh Alger-MacColl , CAT(C)
Various issues that exist in the upper quadrant of the body can
initiate a snowball effect for injuries and conditions down the
entire chain; whether it is laterally through the peroneal muscles,
posteriorly down to the gastro/soleus complex or via the spiral chain
down through tibia into the plantar fascia. This article will focus
more so on a common condition treated by therapists of various
professional designations; Plantar Fasciitis, and identify how an
upper body issue can be the root cause of a condition presenting
in the foot. This article will shed light on an all too often overlooked
aspect of assessment and treatment; find the cause, treat the cause.
This is a well-known phrase in my clinic and one we try to abide
by with each and every new assessment. Below is a flow diagram
of how a rotation occurring in the mid thoracic spine region can
generate a line of tension down across the posterior aspect of the
body, ultimately leading to tension at the posterior aspect of the
calcaneus, which may lead to plantar fasciitis if not addressed
accordingly.
i. Left T-spine rotation at T7-T10
ii. Right side Erector Spinae Tightness (Spasm)
iii.Anterior Pelvic Rotation on Right Side
iv.Hamstring Tightness (Semitendinosus) on Right Side
v. Right Internally Rotated Tibia
vi.Tightness in Right Achilles Tendon, pulling up on posterior
aspect of Calcaneous
With each of these segmental issues come a myriad of biomechanical
effects in that region. A description of how each issue translates
down the entire chain is detailed below.
i) Left t-spine rotation can result in hypomobility of the
costotransverse (CT) joints at the associate levels. Due to the
rotation the CT joint capsule will be placed on stretch on the right
side as well as the facet joint capsule on the same side. On the
left side, both the CT and facet joints will be compressed. Due to
the hypomobility created at the CT joints, the rib function/mobility
will also be altered, in turn potentially causing problems with the
thoracic diaphragm and efficiency of breathing. The rotation will
also cause the iliocostalis and longissimus erector spinae muscles
groups to be placed on length and in due time will spasm.
ii) The tightness of the erector spinae muscles may alter the joint
mechanics of the sacroiliac joint on the right side. This may create
4
low back pain and potentially gluteus maximus pain or atrophy.
These factors will in inevitably alter the individuals gait pattern,
leading to decreased hip extension on the right side. From the
attachment of the erector muscles, the prolonged tightness will pull
superiorly on the posterior aspect of the iliac crest, causing the right
ilium to become anteriorly rotated.
iii) The resultant anterior ilium rotation can create multiple
biomechanical issues throughout the body. Over time increased
stress can be placed on the medial aspect of the right knee due to
the internal rotation of the femur created at the coxafemoral joint.
The stress at the knee joint can increase the pronation that takes
place at the subtalar joint as well. The ilium rotation will also create a
muscular imbalance with the quadriceps/hip flexors and abdominal
muscles. As the hip flexors will be in a shortened position for an
extended period of time and the abdominal muscles will become
weakened from being on length for so long. Quadratus Lumborum
muscle may also become tight from being in a shortened position;
this will increase lumbar extension (lordosis).
iv) Increased tension will be placed on the hamstring muscles,
specifically semitendinosus, due to the muscle origin on the ischial
tuberosity and the increased pull created with the ilium being
anteriorly rotated. The muscle lengthening will create improper
firing patterns in the muscle and cause it to atrophy over time. This
will in turn affect the ability to perform hip extension and will likely
limit the active range of motion for hip flexion.
v) Due to the hamstrings being placed on length for an extended
period of time, the increased tension in the semitendinosus will
pull the right tibia into internal rotation over time. This rotation
can in turn affect the biomechanics and stability of the knee joint,
increasing the strain on the LCL as well as increasing the tension in
the lateral head of the gastrocnemius muscle. The internal rotation
may also cause the medial longitudinal arch of the right foot to
collapse or simply create over pronation at the subtalar joint.
vi) The achilles tendon will experience a lengthening over time
with the associated tension on the hamstring group. This will cause
the posterior aspect of the calcaneous to be pulled superiorly in
turn placing an increased level of stress on the plantar fascia. The
associated pain with this issue will likely create a compensation
within the individuals gait pattern. The tension on the plantar aspect
of the foot may cause the flexor digitorum muscles to spasm and
increase flexion at the MTP joint at incorrect times.
From all the information presented above, it is clear that the history
and observation aspects of your assessment need to be extensive
and thorough. The assessment form used in clinic should be laid
out with an area for observations that include a general full body
scan to note any major deformities or alignment deficits. Never
discount what patients tell you during their history; more often than
not the answer is in what they are telling you. Attention to detail,
observing and testing functionally in relation to the patient’s job
and/or sport and knowing when to refer the patient to a different
health practitioner for care are the keys to success for a well rounded
pedorthist.
A Periodical of the Pedorthic Association of Canada
Summary of; The relationship
between foot motion and
lumbopelvic-hip function:
A review of the literature
SUMMER 2013
PEDORTHIC RESEARCH
FOUNDATION OF
CANADA UPDATE
Tavish Lahay-Decker , C. Ped (C)
There is evidence that supports the effectiveness of functional foot
orthoses (FFO) in the management of lower limb pathologies, many
of these which are associated with lumbopelvic-hip complex and
particularly gluteus medius (GMed) dysfunction. This relationship
between the foot and lumbopelvic-hip complex is becoming
increasingly investigated due to the effect of lumbopelvic-hip
complex dysfunction and the development of lower limb injuries.
It is thought that dysfunction in this complex can have negative
effects on the more distal structures of the lower limb. Research
into FFO has shown that muscle activity patterns are significantly
altered by wearing FFO whereas other studies have shown that
small alterations in limb kinetics and kinematics can occur, however
results are largely subject specific and can be inconsistent.
The PRFC had another successful fundraising drive
at the 2013 PAC Symposium in Montreal. The total
raised was just under $15,000 and the breakdown of
funds raised is as follows:
Both foot types, pronated and supinated, have been linked to
different types of injury. For example, it is frequently noted that a
supinated foot type is more prone to impact related injuries while
a pronated foot type, which has been investigated significantly
more than the supinated foot, has been associated with tibial stress
fractures, ACL injury, back pain, knee pain and medial tibial stress
syndrome to name a few. Despite this not all studies investigating
the relationship between injury and foot type have supported the
correlation between foot type and injury type. The proposed reason
for this is the presence of abnormal mechanics of more proximal
structures affecting the distal structures. Foot posture has been
suggested to affect more proximal structures with; excessive foot
pronation, shortening of the limb, increased internal rotation of the
lower limb and an anteriorly rotated pelvis position. This altered
pelvis position is thought to increase strain on iliopsoas, piriformis,
and the gluteal musculature, promote narrowing the greater sciatic
notch and cause compression of the sciatic nerve, as well as
increase strain on the sacroiliac and lumbosacral joints and cause
lumbosacral instability. Despite a strong theoretical basis, empirical
data is still lacking in this area.
Major contributors were:
Ribbon Sales
$760
50/50 Draw
$432
Lanyards (Biotech)
$645
Donations
$12,845
TOTAL
$14,682
$5,000
W
OT
EAR • F O O
T
• CA
H C E NT R
E•
ALT
NAD IAN F
O
$5,000
HE
1(
) 8 91- 67
888
9
2
Dysfunction of the lumbopelvic-hip complex can lead to issues with
flexibility, strength and neuromuscular activation, and problems
with force distribution/transfer across joints. Additionally alterations
in neuromuscular activation of GMed has been linked to issues
such as; ankle hypermobility and injuries, iliotibial band friction
syndrome, patellofemoral pain syndrome and low back pain. GMed
plays a vital role in the function of the hip and pelvis as it produces
and controls frontal and transverse plane movement at the hip and
compresses the femoral head inside the acetabulum.
$1,000
In other exciting news, the PRFC has officially
launched our first Request for Proposals. The
deadline for this initial round of funding is
October 31, 2013. Please visit our new website
www.pedorthicresearchcanada.org for details and
funding applications.
Possible biomechanical changes due to lumbopelvic-hip dysfunction
include increased femoral adduction and internal rotation as well as
increased genu valgum. These changes can cause the line of weight
bearing, or centre of pressure, to fall medial to the subtalar joint
5
line and can contribute to increased or prolonged pronation of the
foot and well as GMed dysfunction. Investigation of joint kinetics
and power flow through the lower limb supports this with evidence
showing the dependence of knee and ankle moments on those of
the hip. In addition, there seems to be a correlation between gender
and lower limb function. It has been suggested that during running,
females have greater knee valgus angles, and greater velocity of hip
adduction. Females have also been shown to have a decrease in
hip abduction and external rotation strength. Studies have shown
that weakness in hip abductors causes increased frontal plane
motion at the hip and decreased control over knee motion. FFO
have demonstrated a decrease in peak tibial internal rotation and
increase in the external rotation, flexion and extension moments
and abduction moments at the knee.
as it passes under the arch. Adjustments to intensity and timing of
muscle activation are made in response to this showing that FFO
are capable of altering muscular activity at various phases of the
gait cycle. Increases in peroneus longus and decreased in tibialis
posterior activity have been found during walking, while increases
in vastus lateralis and medialis, peroneus longus, biceps femoris
and medial gastrocnemius activity have been noted. Investigations
into GMed activity is lacking with respect to the response of GMed
to FFO. One study states that GMed activity is increased with
FFO and single leg squats but no changes to lateral step down or
maximal vertical jump tests, however the effect on gait and GMed
activity was not noted.
Sensory feedback provided by FFO has also been recognized
under neuromuscular theory. This theory suggests that FFO
stimulate cutaneous mechanoreceptors, especially the tibial nerve
You can look
everywhere for just
any GLUE ...
any
erm
G
n
ei
Mad
... we have the perfect
adhesive for your needs!
BONDING IS OUR CHALLENGE
RENIA GmbH · D-51109 Köln · Ostmerheimer Str. 516 · Tel.: ++49-221-630799-0 · www.renia.com · [email protected]
6
www.vkb-werbung.de
Original Article: Barwick A, et al. The relationship between foot
motion and lumbopelvic-hip function: A review of the literature.
Foot (2012), doi: 10.1016/j.foot.2012.03.006
A Periodical of the Pedorthic Association of Canada
SUMMER 2013
History Taking 101
Crystallee Ripak, C. Ped (C)
Pedorthists utilize numerous tools in order to assess and treat their
patients. When asked to list what these tools are, things that may
come to mind could be physical tools like a goniometer or brannock
device or something like gait analysis. A detailed patient history
may not be the first or the fanciest thing that comes to mind, but it
can be one of the most useful and powerful things in the toolbox.
Here are a number of small sayings that can help you continue to
master this tool.
Always be prepared.
The motto of the boy scouts does always seem to be applicable.
To ensure that a complete picture is gained it is critical to have a
structure to follow for your history. Whether the structure comes
in the form of a mental checklist or physical list of items and/or
questions; it is a matter of personal preference. Information should
be gathered about the chief complaint (including onset, duration,
quality, aggravating and ameliorating factors etc…), general health,
activities of daily living, current medications (keep in mind that
in some cases that symptoms can also be caused or the result of
side effects from medication), past injury and surgery and patient
expectations. Without being prepared it can be easy to miss
something along the way when so much information needs to be
gathered and recorded.
Listen.
Be present with each patient. Recognize that it can be therapeutic
for the patient to recount the story of their problem or injury. Don’t
let distractions enter the mind or start mentally preparing for the
next phase of the appointment, take the time to listen. Be an active
listener. It can aid in keeping you focused and also ensure that you
understand all of what the patient is saying.
It’s not always about what is said.
Pay attention to the non-verbal aspects of communication. Tone of
voice, eye contact, and body language are just some of the ways
that people communicate non-verbally. Things like leaning forward,
making eye contact and the occasional nod can effectively reassure
the patient that we are listening and engaged in the conversation. It
is also interesting to note that studies have been completed looking
at non-verbal communication between doctors and their patients
and how it can affect clinical outcomes, adherence and patient
satisfaction.
While the main goal of the history is to gain information and
understanding regarding the patient’s chief complaint, it also aids
in determining the direction and the outcome of the visit. When
taking a detailed patient history the pedorthist becomes a detective;
discovering the what, where, whens and whys with the clues that
the patient is providing. By being prepared, listening and staying
aware of the non-verbal aspects of communication a pedorthist can
master the use of this tool.
Bibliography
History Taking. (n.d.). Retrieved May 2013, from Patient.co.uk: http://
www.patient.co.uk/doctor/History-and-Physical-Examination.htm
Lorimer, D., French, G., O’Donell, M., Burrow, J. G., & Wall, B. (Eds.).
(2006). Neale’s Disorders of the Foot (7th Edition ed.). Edinburgh:
Elsevier.
Roter, D., Frankel, R., Hall, J., & Sluyter, D. (2006). The Expression
of Emotion Through Nonverbal Behavior in Medical Visists:
Mechanisms and Outcomes. Journal of General Internal Medicine ,
21 (Suppl 1 ), S28-s34.
2014 PAC Symposium
Niagara Falls, Ontario
April 4 & 5, 2014.
Keep your eye out for the exhibitor guide coming soon!
7
Elastic Therapeutic Tape and
the Foot Care Professional
leslie trotter, BSc, MBA, C. Ped (C), MSc
As foot care professionals, sometimes our advice and treatment are
undermined by patients resuming the same activities that landed
them in our offices in the first place. How exciting would it be to
have a sticky, stretchy little assistant that reminded our patients for
2-5 days about positional awareness?
Enter…. elastic therapeutic tape!
By now, the vast majority of practitioners
have had some exposure to elastic
therapeutic tape (ETT) or “kinesio-tape”,
the commonly used brand name of
developer Kenzo Kase. ETT companies
claim it “reduces muscle soreness,
improves function, decreases bruising,
and decreases pain”. To varying extents,
these claims appear to be accurate.
Anything that touches the body’s
biggest organ, the skin, has a cutaneous
mechnanoreceptor effect that stimulates
receptors to enhance body kinesthesia
or movement awareness. By stimulating
large skin mechanoreceptors, kinesiology
tape can also downgrade painful stimuli from the nociceptors, which
decreases pain perception.
Early and persistent reasoning suggested that using the tape in an
“origin to insertion”, or “muscle action” methodology, best serves
to support/stimulate external body areas. While this approach
probably makes the most intuitive sense to medical practitioners as it
follows anatomical “rules of engagement”, emergent theories, which
consider entire postural muscle groups, are making a strong case.
Dr. Steven Capobianco, developer of the Fascial Movement
Taping (FMT) method argues that taping should be “based on
the obvious yet largely overlooked
concept of muscles acting as a chain…
the body’s integration of movement
via multi-muscle contractions as a
means of connecting the brain to the
body’s uninterrupted fascial web in
order to enhance rehab and athletic
performance via cutaneous (skin)
stimulation. By taping movement rather
than muscles, FMT has demonstrated
greater improvement in both patient
care and sport performance. “
Dr. Capobianco is not alone in this line
of thinking. Leading fascia researcher,
Robert Schleip PhD, underscores
movement and its role in pain and
dysfunction1. Additional support for this model comes from Thomas
Myers in his ground-breaking book, “Anatomy Trains”. He offers a
Included are a few common musculoskeletal conditions where foot care professionals can utilize elastic
therapeutic tape to enhance proprioception and quite possibly the outcome. For step-by-step video instruction
on applying ETT for a variety of lower limb complaints, go to www.rocktapecanada.com > videos > feet & hands
8
A Periodical of the Pedorthic Association of Canada
SUMMER 2013
There’s a notable difference in the hematoma on this biceps tear just 48 hours after the use of ETT.
template to assess, treat, and manage body-wide motor dysfunction
based on myofascial meridans, and movement impairment.
Recent research indicates that kinesiology tape has a greater
stimulatory effect with compromised tissue (due to injury or fatigue
due to poor posture). Thedon, et al3 conducted a study to evaluate
body sway in individuals with and without tape. They found that the
tape showed very little change in the uncompromised condition,
but when the subjects were fatigued, the tape provided an added
stimulatory effect to the skin helping to compensate for the loss of
information fed to the brain from the muscles and joints. For the
pain and performance community, this study provides insight into
an “auxiliary” system, such as the skin, to augment treatment and
training outcomes.
A 2012 study 4 of 32 surgeons, showed a statistically significant
reduction in neck and low back pain (using Oswestry Low
Back Disability Index and Neck Disability Index) and functional
performance (using neck and low back range of motion scores)
with the use of ETT during surgery. This may have far-reaching
implications for other jobs/activities where sustained positions
result in musculoskeletal pain.
The value of ETT was underscored for me recently when a patient
who had been suffering from plantar fasciitis for 2 years commented,
“the pain is growing”. She traced a line from the insertion of the
tibialis posterior along the peroneus longus and into her lateral
gastrocnemius.
9
Out of desire to help her immediately, I pulled out the ETT. I made a
continuous sling of tape from her peroneus brevus, pulling her foot
slightly into inversion, tracing a fascial spiral along the tibialis and
peroneal group right up to the head of her fibula. I finished with a
“compression strap” of 50% stretch across the lateral gastrocnemius
where she indicated the most point tenderness. Then, like most busy
practitioners, I forgot about Julie until 3 days later when our office
manager received a call from her wanting to know “what the heck
was in that tape” and why hadn’t she “been offered this treatment
months ago?” She had apparently experienced 2 pain-free days in
her calf for the first time in recent memory. Julie returned that very
day to buy a roll of tape and to have me show her how to self-apply
for her particular symptoms.
While not a panacea for all musculo-skeletal pain of the lower limb,
Julie’s success using ETT is certainly not isolated. It works very well
for patellar tracking issues (think of all the “colt-like” teenage female
basketball/volleyball players with sore knees!), tibialis anterior/
posterior tendonitis, gastrocnemius strain, Achilles tendonitis,
inversion sprains and (here’s the semi-magical part) edema! The
protocol for contusion and edema is nothing short of fascinating.
Because the tape literally lifts the skin, rather than compressing it,
the micro-circulatory system (lymphatic and venous) is enhanced
rather than constricted. The elastic pull on the epidermis/dermis
layers creates an area of lower pressure to assist in fluid dynamics
(acute/chronic edema).5
Clearly the use of ETT tape is popular (millions of users) and the
applications are broad (from athletic injuries to edema). Specific
evidence for efficacy is scant but growing, and plausible. There are
currently no reported dangers associated with using this elastic
cotton mesh bandage, and the only significant contraindication
is on open wounds. Good quality ETT breathes well and flexes
like a second skin, unlike most braces that act more like abrasive
exoskeletons. It withstands sweat and/or water and is by most
comparisons a cost-effective treatment modality.
While science is unlikely to discover that ETT is useful for all aches
and injuries, foot care practitioners should consider its use in their
practices.
References:
1. Schleip R, Muller D. Training principles for fascial connective
tissues: Scientific foundation and suggested practival applications.
J Body Move Ther 2012;1-13
2. Myers, T.W. 2009. Anatomy Trains: Myofascial Meridans for
Manual and Movement Therapists. New York: Churchill-Livingston.
3. Thedon T, et al. Degraded postural performance after muscle
fatigue compensated by skin stimulation. Gait Posture, 2011
Apr;33(4) 686–9
4. Karatas N, Bicici S, Baltaci G, Caner H. The effects of kinesiotape
application on functional performance in surgeons who have
musculo-skeletal pain after performing surgery. Turk Neurosurg
22(1):83-9, 2012
10
5. Chou YH, et al. Case Report: Manual lymphatic drainage and
kinesio taping in the secondary malignant breast cancer-related
lymphedema in an arm with arteriovenous fistula for hemodialysis.
Am J Hosp Palliat Care. 2012 Aug 9
Additional Reading:
• Konishi Y. Tactile stimulation with kinesiology tape alleviates
muscle weakness attributable to attenuation of Ia afferents, J Sci
Med Sport, June, 2012.
• Thelen M, et al,The clinical efficacy of kinesio tape for shoulder
pain. A randomized, double blinded, clinical trial. Journal of
orthopaedic & sports physical therapy, volume 38(7), July 2008
Forgotten Conditions:
Four conditions you may
forget to consider during your
Pedorthic assessment
Tarsal Coalition
Melissa Rabbito Lujan, C. Ped (C)
A tarsal coalition is defined as a union between two or more tarsal
bones of the foot. Coalitions can be further classified as osseous
(boney), non-osseous (cartilaginous) or fibrous (sydesmosis). The
most common sites of coalition are at the calcaneonavicular (CN)
joint or the talocalcaneal (TC) joint. Tarsal coalitions typically affect
adolescence, with presentation of symptoms occurring between
the ages of 9 and 16. Patients will typically present with a rigid
pes-planus foot type, limited ankle range of motion and possible
peroneal spasm. Although the condition can create symptoms of
ankle pain, not all patients are symptomatic.
Clinical testing should focus on an in-depth history taking and range
of motion testing. History taking will reveal a pes planus foot type
from an early age, with no drastic change in foot shape over time.
In unilateral cases, one foot will have developed a ‘normal’ shape,
what the affected side remains pes planus. Symptomatic patients
will typically present with “ankle pain” which is aggravated by
activity. Although tarsal coalitions are congenital and present from
birth, the symptoms are often exacerbated by a traumatic event
such as an ankle sprain. This may mislead patients to believe the
sprain was a contributing factor. Other patientsmay experience an
insidious onset of symptoms with no associated trauma.
Range of motion testing will reveal limited subtalar joint range of
motion, particularly passive ankle inversion. Palpation may reveal a
mass or tenderness at the site of the coalition. Upon weight-bearing
there is no change in foot or arch shape from the non-weight bearing
position. Clinical tests should include the Hubscher maneuver and
the heel tip test. For the Hubscher maneuver, the patient stands
in a position while the clinician passively dorsiflexs the great toe.
This motion should activate the Windlass mechanism and cause
the medial longitudinal arch (MLA) to visibly rise. In patients with
tarsal coalition the rise of the MLA will not occur. While the patient
A Periodical of the Pedorthic Association of Canada
is standing, the clinician can also do the heel tip test. This is done by
supinating the foot by manually raising the MLA. Due to the coupled
motions of supination and tibial external rotation, the tibia should
rotate outwards, this motion will not occur in patients with tarsal
coalitions.
A clinician can use the above tests to determine an index of suspicion
or confirm a diagnosis however, a definite diagnosis requires
diagnostic imaging, either oblique x-rays, MRI or CT of the foot.
Asymptomatic patients should not be treated aggressively.
Supportive footwear and regular observation are recommended.
Symptomatic patients can be managed conservatively with options
such as: oral anti-inflammatories, activity modifications, orthoses
and shoe modifications. Orthoses should be UCLB style with high
medial and lateral borders and a navicular excavation if the area
becomes irritated. Off-the-shelf inserts are NOT appropriate for this
population, as the prefabricated arch support is often too aggressive
for their pes planus foot type.
In severe cases where conservative treatment options have failed,
complete immobilization with a walking boot for 3-6 weeks would
be suggested. A small portion of patients may require surgical
consultation.
REFERENCES:
1. Clinical Practice Guidelines (2012)
Lisfranc Injury
Patrick Bergevin, C. Ped (C)
SUMMER 2013
Complications:
• Burroughs et al. (1998) reports posttraumatic arthritis to be the most common
complication of Lisfranc joint injury. He further reports the
complications are directly related to the degree of comminution of
the articular surface in the joint.
• Wheeless (2011) reports that possibly up to 50% of cases develop
resulting arthritis or pes planovalgus deformities.
• Several authors report compartment syndrome to be a very
common sequelae, the main cause being disruption of the dorsalis
pedis neurovascular complex.
Geerling et al. (as citied in Burroughs et al., 1998) reports that even
today, these injuries are frequently missed because they often
occur in patients with multiple traumatic injuries, but low energy
trauma to the foot might also lead to difficulties in diagnosis due
to a heterogeneous clinical appearance. Englanoff et al., as well as
Trevino et al. (as cited in Burroughs et al., 1998), report that as many
as 20% of Lisfranc joint injuries are missed on initial anteroposterior
and oblique radiographs.
Common Treatment
• Custom, corrective foot orthotics (intrinsic or extrinsic posting).
These devices are advised for both stable and surgically-repaired
injuries. Metatarsal pads also help support the distal metatarsals,
but may not be tolerated in more acute cases.
• Wadsworth &Eadie (2005) specifically used custom-made orthotics
with standard 4 degrees of medial posting, 15-degree medial heel
skives as well as metatarsal pads for his study
Lisfranc injuries occur along the tarso-metatarsal (TMT) joint
complex, which indirectly bisects the midfoot in the frontal plane,
and can involve one or many of the five tarso-metatarsal joints
(Trevino 2009). Often referred to as a Lisfranc fracture dislocation, it
presents in varying degrees, not always involving fractures. Unlike
the plantar aspect of the foot, there is limited tissue on the dorsal
aspect of the foot to prevent convex or dorsal dislocations (Raikin
et al., 2009).
The mechanism of injury can be direct (direct trauma such as motor
vehicle or crush injury), or indirect (axial loading of plantarflexed
ankle and forefoot, with toes extended) (Aronow, 2006). Lattermann
et al. (2007) classifies the causes as low or high energy, associating
low velocity injuries to sports, and high velocity injuries to motor
vehicle accidents. They further divide low velocity injuries into
forced hyperplantarflexion of the midfoot in athletes using foot
straps (surfers, windsurfers, equestrians).
The role of the Pedorthist is not in diagnosing the severity of the
displacement or instability, but in being familiar with the reasoning
behind the decision to treat conservatively or operatively. To
summarize the decision process, most authors report a 2mm
displacement to be the “benchmark” measurement between non
operative and surgical repair. Other factors affect the decision,
including the presence of metatarsal fractures, presence of joint
comminuting (involvement of other joints) (Burroughs et al., 1998;
Lattermann et al., 2007), and most importantly, midfoot instability
(Raikin et al., 2009).
837 Sargent Avenue Winnipeg, Manitoba R3E 0C1 Canada
We pride ourselves on offering only high
quality materials and components for your
fabrication needs.
We appreciate the opportunity to do
business with you.
Check us out and see what we have to offer.
www.myrdalorthopedics.com
Toll Free 877.395.0081
11
• Taping of the plantar portion of the foot to support the midfoot and
stabilize the forefoot. Wadsworth &Eadie (2005) states the main
goals of taping as being increased plantarflexion of first ray to
stabilize forefoot during push-off, to promote first MPJ extension
and to provide support and shortening of the longitudinal arch of
the foot
• Icing 10-15 minutes to area, especially at night
• Avoid barefoot walking; molded cork footbed type footwear should
be worn outdoors
• The lacing of the shoe can be changed, by not “criss-crossing” the
laces in the area of dorsal prominence of cuneiform.
• Physiotherapy for gait and proprioceptive retraining (Wadsworth
&Eadie, 2005)
Reference
Aronow, M. (2006). Treatment of the missed Lisfranc injury. Foot
and Ankle Clinics 11, 127-142.
Burroughs, K.E., Reimer, C.D. & Fields, K.B. (1998). Lisfranc injury of
the foot: a commonly missed diagnosis. American Family Physician,
58, 118-124. Retrieved from http://www.aafp.org/afp980700ap/
burrough.html
Lattermann, C., Goldstein, J.L., Wukich, D.K., Lee, S. & Back B.R.Jr.
(2007). Practical management of Lisfranc injuries in athletes.
Clinical Journal of Sport Medicine, 17, 311-5
Raikin, S.M., Elias, I., Dheer, S., Besser, M.P., Morrison, W.B. & Zoga,
A.C. (2009). Prediction of midfoot instability in the bubtle Lisfranc
injury. Journal of Bone and Joint Surgery, 9, 892-899
Trevino, S.G. (2009). Lisfranc fracture dislocation. Retrieved
from
MedScape
website:
http://emedicine.medscape.com/
article/1236228-overview
Wadsworth, D.J.S. & Eadie, N.T. (2005). Conservative management
of subtle Lisfranc joint injury: A case report. Journal of Orthopaedic
& Sports Physical Therapy, 35, 154-164. doi:10.2519/jospt.2005.1365
abnormalities such as excessive pronation, overuse in sports,
footwear with cleats, and increased metabolic activity in the growth
plate.
Due to the location of pain, Sever’s Disease can be mistaken for
Achilles tendonitis and retrocalcaneal bursitis. Other differential
diagnoses include pump bump, plantar fasciitis, calcaneal stress
fracture, sub-talar joint arthritis and heel contusion.(1)
The symptoms from Sever’s Disease will not be sudden; rather it
will be a gradual onset of pain.(2) Pain and tenderness will be felt
throughout the back of the heel. The pain is typically activity related
and will usually be quite intense during the activity and then subside
with rest.(3) Physical examination demonstrates decreased gastrocsoleus flexibility. The heel pain will be reproduced by palpating over
the apophysis or with the calcaneal compression test.(2)
The main goal with treating Sever’s Disease is to decrease
inflammation and stress placed at the apophysis.(2) This can be done
in several different ways depending on the individual. If there is
any significant abnormality with their biomechanics such as over
pronation, then foot orthoses can be used to stabilize the hindfoot
and reduce the strain ion the Achilles tendon. Heel cups or ¼ inch
heel lifts can be used to decrease tension on the Achilles tendon
as well.(1,2) It is important that proper footwear is being used. This
includes the right type of shoe for their feet as well as a shoe that
is the right size. Stretching of gastroc-soleus complex will help to
reduce tightness. Physiotherapy can help to achieve better flexibility
as well. Other treatments include rest, ice and Nsaid’s.(1,2,3)
REFERENCES:
(1) Clinical Practice Guidelines (2012)
(2) Chorley, J., Powers, C.R. (2012, July 25). Clinical features and
management of heel pain in the young athlete. UpToDate.com.
Retrieved May 8, 2013 from http://www.uptodate.com/contents/
clinical-features-and-management-of-heel-pain-in-the-youngathlete?source=search_result&search=severs+disease&selected
Title=1~17
Wheeless, C. (2011). Lisfranc’s fracture/Tarsometatarsal injuries.
Retrieved from Duke Orthopaedics presents website: http://www.
wheelessonline.com/ortho/lisfrancs_fracture_tarsometatarsal_
injuries
(3) Prentice, W.E. (2003). Arnheim’s Principles of Athletic Training:
A competency-based approach (11th ed.). New York, NY:
McGraw-Hill
Sever’s Disease
Matt Neufeld, C. Ped (C)
Matt Neufeld, C. Ped (C)
Sever’s Disease (also known as calcaneal apophysitis) is one of the
most common causes of heel pain in young athletes.(2) The calcaneal
apophysis is the growth plate at the insertion of the Achilles tendon.
The apophyses serve as origins for muscles on growing bone and
provide bone shape.(1) The mean age of this condition is between the
ages of 8 and 12 and it is more prevalent in boys than girls.(2) Sever’s
disease is caused by the pull of the Achilles tendon on the traction
epiphysis of the calcaneus.(1) The pain with this condition is a result
of inflammation, which can be caused by several different factors.
Some of these factors include: improper footwear, biomechanical
12
Tarsal Tunnel Syndrome
Tarsal tunnel syndrome, also known as posterior tibial neuralgia,
occurs when the posterior tibial nerve becomes compressed within
the space of the tunnel.(1) That tunnel is located on the medial side
of the ankle joint. The tunnel consists of the small space extending
from the posteromedial ankle to the plantar aspect of the foot.(1)
The posterior tibial nerve branches into the medial plantar nerve,
lateral plantar nerve and the medial calcaneal nerve. Tarsal tunnel
is the most common entrapment condition of the foot and lower
extremity.(1) The most common cause of tarsal tunnel syndrome
is either a fracture or dislocation involving the talus, calcaneus or
medial malleolus.(2) Some other common causes include excessive
pronation, ligamentous injury to the ankle, ganglion, engorged
A Periodical of the Pedorthic Association of Canada
SUMMER 2013
veins, arthritic problems, trauma and obesity.(1) Essentially, any
problem that involves inflammation can decrease the space within
the tunnel and therefore cause or exacerbate the symptoms. In
the upper tunnel, it is most common for lesions to cause nerve
entrapment, whereas mechanical problems are more likely to cause
the entrapment in the lower tunnel.(1)
A thorough clinical exam including a detailed history is very
important to help determine if you are dealing with tarsal tunnel
syndrome. One of the more common tests used is Tinel’s Sign.(1,3) To
perform this test, tap on the posterior tibial nerve as it passes along
the medial portion of the ankle. A positive test will reproduce the
symptoms.(1) If there is no response to other conservative treatments,
a referral for nerve conduction testing can be valuable.(1)
From the patient’s perspective, some common words to describe
their symptoms include: painful, burning, aching, numbness, and
tingling.(1,2) The entrapment does not subside when non weightbearing, therefore the discomfort is the most irritating at night(2) and
can wake them up or keep them up during the night.(1) The nerve like
symptoms will commonly be presented around the medial ankle/
heel and into the foot. In some cases the pain may move into the
toes if more than one nerve is entrapped(1) or may radiate up the
calf and higher.(2) Chronic cases may show atrophy and weakness of
the intrinsic muscles(1), but only when the condition is quite severe.(2)
Due to the location of symptoms of tarsal tunnel syndrome, some
differential diagnoses may include plantar fasciitis, heel spurs, and
heel pain syndrome.(1) Sciatica and peripheral neuropathy may
also mimic this condition.(1) In general, however, true tarsal tunnel
syndrome is most commonly diagnosed in patients with clear
antecedent foot trauma.(2) Without such history, “idiopathic” tarsal
tunnel syndrome is quite rare.
Taking a more conservative approach is typically the first step in
treating tarsal tunnel syndrome. It is important that proper footwear
is being used.(1,2,3) Not only do the shoes need to fit correctly, but
they need to have proper structure and support. If footwear alone
is not giving the feet enough support, foot orthoses can be added
to help with alignment and improve foot mechanics.(1,2,3) Manual
therapy, massage therapy and/or physiotherapy may be helpful
in releasing the retinaculum and reducing scar tissue build up.(1)
Other conservative treatment options may include NSAID’s,
braces, self massage and leg elevation.(1) Corticosteroid injections,
although more invasive, may provide relief and can also be used
diagnostically.(1) Surgery is another more invasive option.(1)
REFERENCES:
(1) Clinical Practice Guidelines (2012)
(2) Rutkove, S.B. (2013, Jan 7). Overview of lower extremity
peripheral nerve syndromes. UpToDate.com. Retrieved May
8, 2013 from http://www.uptodate.com/contents/overview-oflower-extremity-peripheral-nerve-syndromes?source=search_re
sult&search=tarsal+tunnel+syndrome&selectedTitle=1~13
(3) Prentice, W.E. (2003). Arnheim’s Principles of Athletic Training:
A competency-based approach (11th ed.). New York, NY:
McGraw-Hill
2013 NEW
CERTIFICATIONS
The College of Pedorthics of Canada would
like to congratulate the following individuals
who
recently
passed
their
certification
examination.
Certified Pedorthic Technician
(Canada)
Andrew Penn, Richmond, ON
Certified Pedorthist (Canada)
Thomas Abraham, Burlington, ON
Rodney Ashfield, Regina, SK
Joi Belyk, Victoria, BC
Chelsea Brown, Chilliwack, BC
Bharti Daji, Belleville, ON
Shalina Edge, Prince George, BC
Raj Mann, Vancouver, BC
Jonathon Matthews, London, ON
Patrick Purves, London, ON
Alex Raynor, Surrey, BC
Nicole Reid, North Bay, ON
Steven Stredulinsky, Abbotsford, BC
Thank you to those who gave their time as
proctors at the spring sitting. Your efforts
are aiding us in continuing growth within the
profession. The CPC always needs more
volunteers in this area, so please get involved.
13
In Our Patient’s Shoes:
Better Bedside Manner for
a Better Business
Kenton Sefcik, R.Ac
Bedside manner is king. Results are king. In that order.
With everyone in their respective field using relatively the same
pool of knowledge, the same approach to treatment and the same
tools of the trade, it begs the question, “What sets us apart?” What
is the defining difference between one practitioner and another?
What makes those few practitioners in every field stand out and
how can we all try to achieve that level of success?
Firstly, we must look at the word ‘success.’ Success is an interesting
topic altogether as it’s such a personal matter. Success for some
could mean financial gain. For others, it could mean notoriety. For
another group, it could mean something entirely different; however,
as practitioners it’s important to work backwards by thinking about
what success means to us as individuals.
With an end-goal pictured in our minds, we can then work backwards
to determine what it will take to reach those goals. Taking the time to
do this work starts to show us that in order to achieve, for example,
an outward display of success, we need to start from within. This is
the key to being successful in any way, shape, form, or field.
Results are important. It’s why we do what we do: we want the
patient to feel better. It’s why we take our vehicle in to get an oil
change: we just want to perform the necessary maintenance to
stave off disaster in the future. But what makes us take our vehicle
to one mechanic versus the other? Is the location close to work? Is
it the fact that they give out free shuttles? Convenience has less to
do with it than we think. If there were five mechanics within a fewblock radius, chances are the busiest one would be more focused
on a single important factor: customer service.
Customer service is a lost art. Authors have made headlines in
the last few years with simple, yet profound, old-school truths
about putting the person in front of us first. Gary Vaynerchuk, for
example, wrote a monumental book for social marketers called,
“The Thank You Economy.” This book detailed the reasons why
large corporations (and small businesses), should be saying ‘Thank
you’ and putting out fires online.
The last time the power went out, Nova Scotia Power brought it
back on quite quickly in my area. I tweeted that they had done a
good job. Not shortly after, they did their part and thanked me for
my kind words. As a customer, I was shocked. I had received a
response from a huge corporation that I didn’t think really took the
time to care about their users.
Again, bedside manner (read: customer service) is king. In every
field, we can find people who are actually not very good at what
they do. They might not get the best results. They might not find
the best techniques or approaches – yet they are busy - perhaps
even busier than someone who has better results, techniques and
approaches.
14
There are definitely some guidelines for better bedside manner and
the first is to smile. Smiling with the mouth is a great start, but taking
the time to smile from the corners of the eyes is genuine. A smile
goes a long way and shows someone that you care. It improves
overall body language as well. If a practitioner is feeling down on
the inside, then the outside reflects this. The inverse is also true,
meaning that if we want to feel happy and exude this in front of
our patients, smiling works. And like yawns, smiles are contagious.
Another key to success is the old adage of putting ourselves in
the patient’s shoes. If we were the patient, coming in with their
health condition that we wanted remedied, how would we like to
be treated? What would we like to have done to us? Remembering
that it’s not about us is important because this simple fact affects
the way we dress, the conversations we have and how we prioritize
phone calls, emails and personal visits.
Many practitioners go to work in gym clothing, hoodies and
sneakers, and expect to be treated professionally. I’ve been on the
opposite side of the coin, receiving a massage therapy treatment
from someone who proceeded to tell me about their weekend binge
drinking and how they recently got a divorce – this practitioner
wondering why they aren’t busy.
As a consumer in today’s world, along with working backwards
with a goal in mind, we can create our own running manual of
better bedside manner. The easiest way to do this is to look at our
environment; look at how businesses are run. See how the face of
each business, large or small, represents the entire company. When
I call Nova Scotia Power, I’m not talking on the phone to CEO Bob
Hant. Instead, I’m speaking to a customer service representative.
Key word: representative.
In the world of alternative and complimentary health professions
this is amplified. Who represents you? Who promotes you? Who
is responsible for your success? What studying better bedside
manner does not do is point the finger outwards. It is an internal
growth exercise where we point the finger back at us.
Finally, it is important to note that not everyone is some uberextrovert with a Tony Robbins personality. This is not supposed to
be about what someone isn’t. Instead, this process is about turning
up the volume on the positive traits that we all have. At the end of
the day, if we really believe that a patient is coming in for some
super-secret technique that is only available to the ultra-elite, or that
they are coming in because we offer some product that can’t be
bought anywhere else, we’re fooling ourselves.
A patient comes in for the practitioner-patient interaction. A new
patient is most likely due to a referral and already has a good
idea about how things are done at that clinic. We can’t control the
markets. We can’t control what our competition is doing. However,
there’s one thing within our complete control: ourselves.
May you make it yours.
Kenton Sefcik is a husband, father, Registered Acupuncturist, published
author, motivational speaker and martial artist. More information at
harbourhealth.ca or facebook.com/harbourhealth
A Periodical of the Pedorthic Association of Canada
SUMMER 2013
Top 5 Functional Tests to
Consider in Your Pedorthic
Assessment
Rileigh Alger-MacColl , Cat (C)
1. Knee-to-Wall Test
How to Perform:
Place a ruler on the floor perpendicular to a wall. Have the patient
line their foot up along side the ruler with their heel in-line with the
far end of the ruler to begin. While keeping their heel on the ground,
have patient bend the knee as far as possible; attempting to touch
their knee to the wall. If this task is easy, slowly move foot further
away until patient is unable to touch their knee to the wall. Compare
bilaterally the measurements taken by lining up the big toe to the
corresponding mark on the ruler.
What it tells you:
If a discrepancy exists between measurements, this can indicate a
potential issue with the gastroc/soleus complex or adhesions along
the Achilles tendon. This will in turn play into the restrictions along
the plantar fascia and the range of motion that exists about the
joints within the foot.
2. Standing Forward Bend Test
How to Perform:
Step #5: While maintaining step #4, the patient is instructed to
actively dorsiflex the ankle.
Step #6: Patient is instructed to gently release the neck flexion (i.e.
look up slightly). Once again, the presence or absence is identified.
The slump test is considered positive if the patient’s symptoms
were produced in step #4 or #5 but alleviated when cervical flexion
is released.
What it tells you:
If positive this test can help identify Neuromeningeal tension
or simply hamstring tightness. Either way, it is important to
differentiate between the two to ensure hamstring restriction is
addressed if positive, as this can skew foot evaluation.
4. Piriformis Length/Tension Test
How to Perform:
Have patient lie prone on a table with both knees bent up to 90
degrees. Ask patient to let feet drop out to side while keeping knees
together. The side in which the foot drops to the side the least is
indicated as positive or “tight”
Examiner stands behind patient who has their back towards you.
The examiner places each thumb on the PSIS’s simultaneously. The
patient then bends forward to their flexibility tolerance. A positive
test occurs when one PSIS is noted to move in the superior direction
more than the other.
What it tells you:
What it tells you:
5. Gluteus Medius Muscle Strength Test
This will identify hypomobility of the sacroiliac joint. The side
that rises higher in this test identifies a lesion in the SI joint and
a possible rotation of the ilium or even the sacrum. A positive test
can skew the results for leg length, as the rotation will identify a
functional leg length difference, not structural.
How to Perform:
3. Slump Test for Dural Tension
How to Perform:
Step#1: Patient sits comfortably upright
Step#2: Patient is instructed to slump the shoulders and lower back
by slouching without flexing the neck.
Step #3: While maintaining step #2, the patient is instructed to
tuck their chin to their chest while the examiner may apply gentle
overpressure into cervical flexion. The presence or absence of
neurological symptoms is identified.
Tightness in piriformis can cause a rotation of the sacrum, in turn
creating a pelvic rotation which can create a functional leg length
discrepancy i.e. a false positive during evaluation.
Have patient lying on their side on the table. Ask patient to abduct
their leg in this position; ensure that you stabilize their hip with on
hand so they do not tilt hip backwards to recruit the psoas. Once
leg is abducted, apply a pressure downwards in the plane that the
leg was lifted. A positive test is indicated when patient is unable to
abduct the leg and hold and/or when pressure is applied to the leg.
What it tells you:
A weakness in the glute med muscle can significantly play into
the mobility that occurs about the foot. More often than not, an
individual with a pronated foot type will present with significant
weakness in their glute med muscle; this should be addressed with
isolated strengthening exercises.
Step #4: While maintaining step #3 the patient is instructed to extend
the knee. The presence or absence of symptoms is identified.
15
PAC 2013 Symposium
Jason Power, C. Ped (C)
Another Pedorthic year has passed and a new one has been kicked
off at our Pedorthic Symposium in Montreal.
It is said, “April showers bring spring flowers” Well in the Pedorthic
world – Our Pedorthic Symposium brings; showers of knowledge,
understanding, and opportunity with a sprinkling of wisdom and
charge of energy to rejuvenate us and serve our clients and in
prosperity until next spring.
Any such article would be amiss without first thanking all our
conference vendors, conference committee members and co-chairs,
the PAC Management Team - Strauss, and all the participants.
Thank- you all!
The Symposium provides vendors and members an avenue and
opportunity to put names to faces, as well as various committee
members and directors that talk on conference calls throughout
the year. The Symposium allows personal growth and provides a
foundation for building new relationships and strengthens the ones
we have come to nurture and cherish over the years. This year was
no exception.
It was our best participant and vendor turn out ever, with 280
attendees and 46 vendors stretching across the globe from three
Continents- North America, Europe, and Australia and more than
four countries. I have heard that the choice of potential locations to
host our symposiums is not getting easier, as fewer venues exist
to hold our increased numbers of enthusiastic participants and
vendors alike. We are growing and growth is good!
I must say, this year’s Symposium felt more like the first conference
I was at, as I was surrounded by more new faces, than those I
recognized. Hi to the new people I met; it was a pleasure to have the
time to talk with you over a meal and beverage and to listen to your
stories and experiences- please keep in touch. Welcome to those I
have not met yet and to whom we will come to know and rely on,
on our committees and boards of the future.
To single out or highlight lectures or vendors to talk about would
do them injustice. They all gave their time equally and answered
our questions and challenged our knowledge. Plus we do not all
attend to gather the same information. If you want to know what
happened or what was new, who was representing what, or what
was reported, you really need to make it a priority to experience it
next year or contact a colleague and ask!
I will say, however that I do recall one vendor indicating they enjoy
the PAC’s Exhibit Hall and Symposium the most, of all the ones they
attend, because they learn the most from us. They enjoy that we
continually ask genuine, good and challenging questions, seeking
understanding and provide them with suggestions, allowing them
to know us, and improve their products and services better. So
continue to ask when you are getting your exhibit hall passport
filled out.
16
This year’s Symposium social was held at Les 3 Brasseurs St. Paul
in old Montreal. As always there was a great turn out and lots of free
flowing conversations, etc, between all. I think the highlight and ice
breaker of this year’s event was the availability and addition of the
three artists, at the event, that did portraits and charactertures of
the willing , coerced and bribed. This was a great hit providing lots
of discussion, smiles, laughs , and good natured roasting- spirited
by the unique presence each artist captured of our colleagues and
how well we saw or did not see the resemblance in one’s picture.
Hopefully charactertures can become a Social Night Tradition. One
that will provide future attendees with a great symposium memento
and memories for years come.
The 2013 Montreal PAC Symposium provide attendees a chance to
talk shop and share some best practices, opinions and ides with
our peers. Montreal had something for all taste from shopping to
sports. And, well like apple pie without cheese, is like, a kiss without
a squeeze, so to, would be, a trip to Montreal during hockey season
without a chance to see the Habs. Thanks to the organizers for
holding the symposium when two games were on the schedule.
I for one took advantage of this and saw the Canadiens beat the
Winnipeg Jets (at least the last two periods) after the Volunteer
Reception and committee meetings on Thursday.
I can recall being told in school that you make the school, it is
only what you do with in it that makes it good! I also believe our
membership and vendors have heard the same message. This was
evident by the energy in the exhibit hall and lectures this year. Our
vendors, membership and the PAC management team are giverstrue practitioners of reciprocity. Thank you to the 280 attendees and
46 vendors for sending me home rejuvenated and refocused.
A Periodical of the Pedorthic Association of Canada
SUMMER 2013
Pedorthic Technology
Jim Pattison, C. Ped (C)
It was interesting to read in the last PQ about technology in our
industry. There are benefits to the use of technology because they
can help show patients what the problem is and can help provide
evidence to other interested parties. The use of computers can help
with documentation and health records as well.In Montreal, we
saw a lot of technology described in lectures that is both definitive
and expensive.
the best. There is more that needs to be done with this to evaluate
how this works and what is the best placement of the tablet to avoid
artifacts.
At CIATEC in Mexico, there is a lot more technology with
baropodometria, with centre of gravity calculations and force plates
that demonstrate the exact force by the colour the plastic force plate
turns during gait. These are used to statistically quantify how much
more stable one shoe model is than another design and how much
force they dissipate, in addition to studying gait in subjects and
custom making footwear.
Accelerometers can confirm suspicions that a practitioner may
have and show if there is something that is missed. It can also help
analyze complex compensatory gait patterns.
While this technology is useful, it may be out of reach financially
for most of the offices in Canada. This article addresses some items
that are more in line with the finances of most offices. One aspect of
technology not discussed in the last article is the accelerometer. At a
previous PAC Symposium held in Halifax, a speaker had developed a
3D accelerometer to quantify gait. This device recorded acceleration
and displacement in the X, Y and Z axes simultaneously. This device
cost about $15,000 at that time.
In the ensuing years, the same technology has become available at
a much lower cost, with an iPad and Android device. On the iPad, I
have used a free app called SensorLog to begin my look at this. On
the Android, there are 2 apps that appear to do the same - AcMeter
and jAccel. I am in the process of evaluating them to see what works
Fig A: Leg Length Discrepancies
Normal gait sees a normal cycle of peaks and troughs in 3
dimensions. The peaks and troughs should be symmetrical for both
legs. If it is not, there is some reason for it.
Fig A: Leg length discrepancies can show asymmetrical
displacements and accelerations in the X, Y and Z planes because
of compensatory movements. These are runs that I have made with
the accelerometer software. Green is X axis (transverse) , Blue is Y
axis (sagittal plane)and red is Z axis (frontal).
Fig B: A person with insufficient internal hip rotation will need to
compensate for this in their gait. This may be seen with increased
hip rotation in the Z plane or with lateral leaning at the hips. Here is
an example of what increased hip rotation would look like.
Fig C: These cycles should also be in “normal” ranges. A person
with tight calf muscles would demonstrate higher than average
excursion in the Y (sagittal) axis in the gait cycle.
As with many advances in technology available to our industry,
concerns and questions arise that we must ponder when considering
implementing these into our practices.
Fig B: Insufficient Internal Hip Rotation
Fig C: Normal Gait
17
2013 PAC Symposium
The To
rch is p
ass
the new ed as Lisa Iris
h
PAC Pr
esiden becomes
t
erit
M
Award of
eives the unch
c
re
u
a
R
Kimberly the President’s L
at
t at
the Social nigh
Our hosts for asseurs
les 3 br
onstration
Murray Wood gets some dem n
sio
ses
ut
ako
help in his bre
A few of our interna
tional delegates
enjoying the social
night
18
A Periodical of the Pedorthic Association of Canada
Hands on work
SUMMER 2013
y
with Kevin Kirb
A demonstratio
n at PAC’s larg
est tradeshow
to date
the Michael
Brian Scharfstein with
Ryan Robinson presents rial Leadership Award
Van Vlack Memo
Committee and
Happy pedorthists at the red by Mephisto
so
on
Exhibitor Reception sp
Enjoying
al night!
a pint at the soci
A great presentation from Reid Fer
ber
19
Member Profiles:
MIKE FORGRAVE, C. Ped (C)
Mike Forgrave’s passion for athletics
and all sports has brought him to the
Commonwealth & Olympic teams - but his
love of pedorthics has allowed him to open
his own business, and serve in a variety of
roles helping professionals such as the San
Diego Chargers, the Hamilton Tiger Cats
and numerous Olympic athletes.
“I kind of got (into pedorthics) through the back door,” said
Forgrave, who was an elite athlete but got injured. “I went in and
saw a pedorthist, and he helped me. We talked about the profession,
and I was hooked. It was a really exciting thing for me.”
He ended up training with Howard Feigel in 1982, and decided to
continue with the career.
Born and raised in Barrie, Ontario, Mike was inducted into the Barrie
Sports Hall of Fame and still holds the University of Waterloo’s
indoor track record for the 600 metres (1:20.00).
But in addition to his passion for athletics, Forgrave also enjoys
helping all people improve their health. “I love helping people get
healthy,” he said.
“You watch someone come into your office that wants to be active
but they’re overweight, injured, and unfit because their feet hurt.
Working together, they come back a while later and have lost weight,
become mobile and can now do the things they love. Their whole
life has changed, and we need to understand that in our profession
we can make such a difference. We don’t just change lives a little bit,
we change lives a lot!”
sharon horan, C. Ped (C)
Forgrave, C. Ped. (C) earned his credentials from both the American
and Canadian Boards for Certification in Pedorthics.
In 1995, one of Sharon Horan’s employees
convinced her to attend the Pedorthic
Association of Canada (PAC) annual
conference in Ottawa.
“I got my American Certification in 1985 when there was no
Canadian Certification, and attained my Canadian Certification
when the program was only two years old.”
After that weekend, the St. John’s,
Newfoundland native was instantly
hooked.
Over the years, Forgrave has trained other pedorthists, and he
and his associate team are currently clinical pedorthists to 21
southwestern Ontario medical clinics.
“I thought the speakers were fantastic, but even more than the
speakers, it was the questions and commentary that came from the
audience,” said Sharon, owner of Atlantic Orthotics Ltd. located in
St. John’s, Newfoundland. “The Canadian pedorthists made me
realize that there was so much I didn’t know, and I really wanted to
be more effective and improve my patients’ outcomes.”
Forgrave is particularly interested in sports injuries and how
wearing the proper footwear can help athletes train and perform
better. Among many Canadian national teams, he has worked with
track and field, badminton, gymnastics, bobsleigh, downhill skiing,
swimming, figure skating and triathlon athletes.
His favourite part of the job – and what he feels is most rewarding
– is turning on the television and see elite athletics whom he has
helped.
Sharon graduated from Dalhousie University in 1987 with a
degree in occupational therapy. After graduating, she worked
in Newfoundland’s public health care sector in rheumatology –
responsible for hand splinting and foot orthotics. She then traveled
to Kingston, Ontario, where she took a specific foot orthotics course
from an occupational therapist.
“I get a big kick out of helping athletes attain their goals,” Forgrave
said.
“I went on this course, and realized I really liked feet,” she said.
“That was kind of the start of it.”
One of his best memories was when he helped an elite high jumper
set a Canadian record in Europe by modifying his high jump spike.
He later got a call from Nike, who wanted to duplicate the spike
Forgrave had created for the athlete.
Two years later in 1989, Sharon was recruited to work with a
plastic surgeon who was looking for an occupational therapist with
splinting experience.
His dedication to the pedorthic profession has also landed him
awards and special honours – including PAC’s Outstanding
Achievement Award in 2010. He is the only Canadian to receive the
Seymour Lefton Pedorthic Lifetime Achievement Award.
When he’s not working, the University of Minnesota and the
University of Waterloo alumnus still enjoys athletics. A bad knee has
kept him from running, and cycling has become his main activity.
20
While she worked as a hand therapist by day, she decided to open
her own private practice at night called Atlantic Orthotics Ltd.
As the business grew, Sharon hired a pedorthist from Halifax –
who was the same employee who suggested she attend the PAC’s
annual conference.
“I went there that weekend and I literally went home thinking, I need
to be a part of this group,” Sharon said, adding that that’s when she
decided to receive her C. Ped (C) through PAC.
A Periodical of the Pedorthic Association of Canada
SUMMER 2013
In 1994, she left the public sector completely and started FIT For
Work – a division of Atlantic Orthotics Ltd. that specializes in
occupational medicine and injury prevention.
While that company has also grown across Newfoundland and
Labrador, she said she has remained committed to PAC.
“I never left my clinical hands-on connection to feet,” Sharon said.
“I really value my connections, colleagues and the support system.
I just feel like I belong in pedorthics.”
Sharon has remained so committed that she took on leadership
roles within PAC – serving as the association’s past president, and
chairing the College of Pedorthics of Canada.
Sharon said there are many things she enjoys about her work,
including how every day brings something different.
“I love how diverse my week is, but I still manage to have one-onone clinical interactions,” she said, adding that these interactions
make her work most rewarding. “(I love) the impact that pedorthics
make on day-to-day function, and having patients say thank you.”
Sharon is just as busy in her personal life as she is in her working
life. In her spare time, she enjoys the outdoors – from running, to
salmon fishing, to hunting trips.
She is also currently the incoming chairwoman of the St. John’s
Board of Trade – a 900-member business organization.
As a business woman who’s passionate about her community,
Sharon is a proud Rotarian, and recently chaired a $5 million
campaign to build a YMCA in St. John’s.
For Sale
Small Pedorthic Practice
Well established and with a steady client base,
located in beautiful Penticton, BC.
Also attached to this practice is the possibility of continuing
a national distributorship for medical products.
For details contact
[email protected]
Aon is proud to deliver insurance
solutions to the members of the
Pedorthic Association of Canada
including:
•
•
•
Professional Liability Coverage
Clinic/Entity Errors & Omissions
Liability Coverage
Office Package Coverage
If you are interested in learning more about PAC group
insurance, please contact us:
Aon Risk SolutionsTM
333 Preston Street, Suite 600
Preston Square, Tower 1
Ottawa, Ontario K1S 5N4
Direct: 613.722.7070
Toll Free: 1.800.267.9364
Fax: 613.722.2570
Email: [email protected]
www.aon.ca
Aon Risk SolutionsTM is a trademark licensed
for use by Aon Reed Stenhouse Inc.
AFF_A001_0213_RH11478
ESTABLISHED PEDORTHICS
PRACTICE FOR SALE
Victoria, B.C.
Established in 1992, this thriving practice has a
greater than 5,000 active client list and a
large medical professional referral list.
Owner/operator has been slowing down in
last few years preparing for retirement.
Central location fully equipped.
Netted approx. $52,000 in 2011,
less in 2012 as only open part time.
Sale price $109,000
Contact PETER BEVAN of PEMBERTON HOLMES LTD
250-883-3030 or 1-800-665-5303
21
COURSE INSTRUCTOR
PEDS 6021 – PROFESSIONAL PRACTICE FOR PEDORTHISTS
Western Continuing Studies is hiring a course instructor for the course, PEDS
6021 – Professional Practice for Pedorthists, part of the post-degree Diploma in
Pedorthics. The successful candidate will prepare and deliver an online course
totaling 36 instructional hours. This course will be offered next in winter 2014.
Instructional responsibilities include:
• Developing curriculum per current industry trends and standards;
• Loading course material onto learning management system (LMS);
• Undertaking all preparatory work for each class;
• Facilitating discussions a minimum of three times per week;
• Checking email and responding to student questions;
• Setting clear expectations for students;
• Setting and marking tests and examinations;
• Submitting final course grades; and
• Other duties as discussed with Program Manager.
Required qualifications:
• C. Ped (C) in good standing
• 5+ years experience in field
• Particular interest and familiarity with course subject matter
• Experience training and/or teaching adult learners
• Excellent written communication skills
• Familiarity with website design and structure
• Proven leadership abilities
• Exceptional organizational skills
• Ability to work collaboratively with Continuing Studies staff, course
instructors, partner organizations
• Tact and diplomacy
Preferred qualifications:
• Demonstrated success in online teaching
• Experience developing and delivering online curriculum
To apply, please send résumé and covering letter electronically by Friday, August 9, 2013, to:
Chris Thompson
Manager, Post-Degree Programs
Continuing Studies at Western
[email protected]
Thank you for your interest in teaching.
We will contact you for an interview if yourqualifications meet our needs.
Western University Citi Plaza, Unit 240, 355 Wellington St. London, ON, Canada N6A 3N7
t. 519.661.3658 f. 519.661.3799 e. [email protected] www.uwo.ca/cstudies
A Periodical of the Pedorthic Association of Canada
SUMMER 2013
2013 CORPORATE SPONSORS
gold:
silver:
Bronze:
Aetrex
PodiaPlus
P.W. Minor
Renia
23
PAC Symposium 2014
Sheraton on the Falls | Niagara Falls, Ontario
Save the date
April 4 & 5, 2014
for more information visit
www.pedorthic.ca/event-symposium