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Conditions that are successfully treated with orthotics:

Bicycling Overuse Injuries:
Many cycling injuries are caused by training errors and equipment problems, but some are due to biomechanics. Two commonly experienced problems in bicycling which are helped by orthotics are forefoot pain and knee pain.

Pain in the forefoot is very common in bicycling because narrow cycling shoes with or without toe straps squeeze the forefoot. This combined with vibration from the road as well as pressure focused on it from pedaling puts excessive stress on all of the tissues in the forefoot. Pain can come from many sources including:

Hot foot is condition cyclists frequently encounter. It occurs most often during hard pedaling efforts and is due to focused pressure on the balls of the feet . The focused pressure forces blood from the fat pads on the soles of the feet. Which in turn causes heat to build up which is normally dissipated by the circulation causing a burning pain. It is worse in hot weather because body heat builds up more in these conditions.

Riders with high arches and those who pronate excessively experience it more frequently because they have abnormal increased pressure on the ball of the foot. In addition, wearing shoes that are too tight will aggravate this condition, as will tight toe straps because they restrict circulation. Make sure your shoes are not too tight and keep in mind feet swell during long rides or on hot days, so adjust as needed. Most cycling shoes come with little or no sockliner padding and do not dissipate pressure, vibration, and friction well. If such is the case with your shoes, try adding Spenco padded insoles. Moving your cleat position as far aft as possible is also advised. If these remedies prove unsuccessful get custom orthotics. They will balance your foot and redistribute pressure away from the ball of the foot bringing relief.

The same focused pressure and problems with tight shoes that lead to hot foot can also irritate the metatarsal bones, nerves and skin. Cyclists with these problems can also be helped with orthotics. To learn more about these specific conditions follow the links to those topics.

Knee pain in cyclists is very common. It can be from many causes including: training errors, bad technique and poor bike fit, but it can also be from abnormal biomechanics. In regard to training and technique, be sure to use gearing that allows you to keep the resistance low and the cadence at 80-90rpm. Increase the duration and intensity of your rides gradually not more than 10% per week. This will allow your body to adapt to the increasing stress. The cleat adjustment and saddle height are also very important. The seat should be adjusted so you have 145 to 150 degrees of leg extension at the bottom of the pedal stroke. For the cleat adjustment have a bike shop perform a Fit Kit RAD adjustment. This will locate your foot’s most natural position on the pedal, so its not being forced in or out. Even with floating cleats this adjustment is important to get the full benefit of the float.

In regard to abnormal biomechanics, knee pain among cyclists is often the result of excessive pronation of the foot. As the illustrations show, abnormal foot pronation results in increased rotation and angling inward of the leg, creating misalignment and strain at the knee.

The abnormal pronation is the result of angular abnormalities between the forefoot and heel, which causes the arch to collapse. The functional orthotic has forefoot posting added to the ball of the foot on the casts to balance the angular abnormality. This is called intrinsic posting and provides even support from the ball of the foot, through the arch and back to the heel. Some have incorrectly tried to address pronation by placing wedges or cants between the shoe and the pedal. This approach doesn’t work because canting tilts the entire foot and does not address the forefoot to rearfoot relationship. Do not be misled if you have abnormal pronation and knee pain, get orthotics.

Bunions:
"Bunion" is a term loosely used to describe pain in and around the big toe joint. In medical terminology, a bunion is a bursa, or fluid-filled sac, that occurs in a location not normally occupied by a bursa. In the foot, bunions occur over the first metatarsal head (big toe joint) and the fifth metatarsal head . They occur as a result of pressure and friction from shoes over metatarsal heads that are enlarged and prominent. When irritated by tight or ill-fitting shoes, bunions will become red, swollen and painful. Some people have "bunions" and pain which comes from inside the big toe joint and may be caused by trauma, arthritis, or abnormal foot mechanics that leads to wear-and-tear arthritis. Individuals with this have painful and decreased motion, or no motion at all at their big toe joints. Some bunions are caused by arthritis and trauma, but most are due to heredity. Actually, people are not born with bunions, but they inherit the foot type which allows bunions to occur. Over-pronators who have abnormal motions with their first metatarsal bones are likely candidates for bunions. Depending on the structure of the big toe joint, some people get arthritic big toe joints with decreased and/or painful motion, and others get bunions where the first metatarsal bone splays out and the big toe drifts over (hallux abducto valgus), creating a bump that may become irritated by shoes.

If you have decreased or painful motion, use shoes with stiffer soles as they reduce joint motion and pain. For those with hallux abducto valgus, avoid pointed toe shoes and use shoes with wide forefeet and soft uppers. Also, I find a device called a "ball and ring stretcher" is very effective in stretching shoes to accommodate bunions and hammer toes. If your "bunion" is caused by abnormal pronation, orthotics will control the motion that leads to the deformity and should be used.

Flat Feet:

Heel & Arch Pain: (Plantar fasciitis)
The plantar fascia is thick band of connective tissue that runs from the heel bone into the tendons of the toes. It helps to support the arch and aid in propulsion. Inflammation of this tissue is referred to as plantar fasciitis. The symptoms of plantar fasciitis are pain in the heel and arch with standing or walking. It is usually worst when first getting up from bed or after being off your feet for an extended period. For many, the first few steps in the morning are the worst, then it "loosens up" and feels better.

The underlying cause of plantar fasciitis is excess strain on the arch and fascia. This strain causes the fascia to stretch, tear and pull away from its attachment on the heel bone. Inflammation occurs at this site and creates pain. If this process continues for an extended period of time a bone spur may even develop at the fascia attachment. However, the spur itself is usually not the source of the pain. This is because the spur does not project toward the sole and does not bear weight. It is simply growing in response to the pull of the tendon. The pain that occurs at the heel is due to the pull of the fascia and inflammation on the periosteum, which is the tissue that covers bone.

Individuals at risk for his condition are those who are over-weight, those who put excess strain on the arch such as from heavy lifting or with athletes, training errors - especially "too much too soon". It is a common running injury because when running, 3 to 4 times ones body weight goes through their legs with each stride. Even in spite of training properly, some will get this condition. In this case abnormal pronation which leads to arch collapse may be the cause.

To treat this condition, one needs to treat the both the inflammation and the underlying mechanics. To address the inflammation, ice the painful area for 15 minutes twice per day. In addition, oral anti-inflammatories are helpful. The mechanical factors can be broken down into several areas: shoe gear, biomechanics, and for athletes, training. Shoes with collapsed heel counters, which allow the heels to roll in, are harmful, as are shoes with broken-down midsoles or heels which are unstable. Shoes with a cushion crepe midsole are preferable over hard-soled shoes because they provide shock absorption. This is especially important for individuals who do much standing, walking or running on hard surfaces. The mechanical factors can be over-training, too much too soon, excessive body weight and abnormal pronation with arch collapse. If the pronation is mild the condition can often be controlled with over-the-counter arch supports and taping. In more severe cases it may be necessary to fabricate a custom orthotic. An additional aggravating factor can be tightness in the Achilles tendon. If this is present, stretching is advised. So is the use of a night splint. This device prevents the fascia from healing in a contracted position at night greatly reducing the morning pain.   The key element in successful treatment is wearing supportive shoes throughout the healing process and never going barefoot when you are on your feet. It may sound excessive, but even keeping your shoes at the bedside is advised. This can be a frustrating injury because healing can take many weeks, particularly in long standing cases- so be patient. For athletes, cross-training is advised during healing, as well as a gradual return to full activity.

Knee Pain:
Knee pain can be from many causes, including trauma and arthritis, but in some cases it can be due to abnormal biomechanics. Anterior knee pain (front of the knee at the knee cap) is often caused by tracking dysfunction of the patella, or knee cap, in its groove on the femur. This abnormal tracking may cause softening of the cartilage on the under-surface of the knee cap where it contacts the thigh bone or femur. This condition is called chondromalacia patella, and it often affects athletes, particularly runners and bicyclists. It is referred to by some as "runners knee". In the early stages of the condition, softening of the cartilage results, but breakdown of the cartilage has yet to occur. If untreated, permanent damage to the cartilage may occur, which involves erosion of the cartilage.

If you think you suffer from chondromalacia patella, the first thing to do stop the activity that caused the pain. Next, inspect your shoe gear and make sure the midsoles and heel counters on your shoes are not broken down. Broken heel counters and compressed midsoles will allow your feet to roll inward and pronate excessively. This motion imparts an internal rotation and inward angling of the leg which effects how the patella tracks on the femur. Once the pain has resolved, the next step is to strengthen your quadriceps muscles, especially the vastus medalis oblique. This is the muscle on the inside of your knee above the knee cap. Straight leg raises and extension exercises that focus on the last 15 degrees of extension are helpful. Leg press machines are good for this. Avoid leg extension machines where you start with your knee flexed at 90 degrees. A physical therapist or certified athletic trainer can show you what is safe. If you have done all the above and you have new shoes, yet you continue to have pain and you over-pronate, orthotics may help.

Metatarsal Pain:

Neuromas:
Neuromas are growths on the sheaths that surround nerves. In the foot, they are found on the inter-digital nerves between the metatarsal bones in the forefoot. In this location they are referred to as Morton's neuromas. They cause pins and needles sensations, and sometimes burning and numbness, in the balls of the feet and toes particularly at the third and fourth toes. Tight fitting shoes with high heels, narrow toes and little padding are especially bad because they squeeze the metatarsal bones together pinching the nerve. However, individuals who wear "good" shoes may also develop them. This is especially true for athletes and people who put a lot of strain on their feet. Abnormal pronation in these cases may be a contributing factor. Orthotics will redistribute the weight on the foot and reduce the metatarsal movement which irritates the nerve, thus bringing relief. If you suffer from a neuroma, I recommend you start by purchasing metatarsal cookies and place them in your shoes just behind the ball of the foot. For athletic or roomier shoes, Spenco insoles will pad the forefoot and reduce pressure. However, make sure the additional padding does not make your shoes too snug. The shoe needs to be as wide as your foot. If not, consider having the shoe stretched or get a new pair. If the padded insoles don’t help, order a pair of orthotics.

Shin Pain:
The term "shin splints" is a catch-all description of shin pain which can be from many causes. The most common causes include:

The muscles that cause shin pain most commonly are the Tibialis anterior and posterior. Both of these muscles function to stabilize the foot and arch in gait, and help to absorb shock and control pronatory motion of the lower ankle (subtalar) joint. These muscles are in the front (anterior) and back (posterior) of the leg and have tendons that insert into the foot. When these muscles are over-worked or strained, shin pain may develop. Depending on the severity of injury, pain can occur with or without activity. Pain can be in the muscle belly or the muscle attachment on the bone or in the tendon.

Activities which involve running or high impact are common causes of injury. This is because with running, 3 to 4 times ones body weight goes through the foot and leg with each stride, and the muscles are unable to meet these demands. If you have this injury, first rest and ice daily until you are pain free. Then, to avoid re-injury build up your athletic activity gradually by working out initially every other day, and not increasing the duration or intensity of the activity more than 10% per week. For some, it may be necessary to do exercises such as toe lifts with low resistance for the Tibialis anterior, or independent (one leg at a time) heel raises for the Tibialis Posterior. Three sets of 30 repetitions is advised, in order to build endurance. This regimen allows the body to adapt to the increasing stress, avoiding injury. Proper equipment needs to be used as well, and shoe gear needs to be inspected for excessive wear. Shoes must have firm midsoles that provide heel support, and are not broken-down which allow the heel to turn in. The surface one runs on is also important. If possible, run over soft rolling terrain, avoiding steep hills and cement. Despite following sensible training, some athletes have abnormal biomechanics of the feet and need the additional support orthotics provide.

 

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Revised: February 18, 2005

 

 

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