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Pedorthic considerations in the management of the injured worker
Foot Ankle Clin N Am 7 (2002) 403 – 408
Pedorthic considerations in the management of the injured worker Ted Colaizzi, CPed Colaizzi Pedorthic Center, 617 Forest Avenue, Pittsburgh, PA 15202, USA
According to the 27th Dorland’s Medical Dictionary, pedorthics is ‘‘the design, manufacture, fit, and modification of shoes and related foot appliances as prescribed for the amelioration of painful or disabling conditions of the foot and limb’’ [1]. Pedorthics uses footwear, including foot orthoses, to help ease foot problems. A certified pedorthist (CPed) works as part of the allied health care team, dispensing footwear to keep people as mobile as possible. Shoes can be customized or modified to fit an individual’s needs; they can also be custommade or handcrafted over a standardized model, called a shoe ‘‘last,’’ or custommolded or handcrafted from a model of the patient’s own foot (Fig. 1). Pedorthic care of the injured worker starts with a complete pedorthic evaluation. The evaluation includes important patient information, such as activity level, work environment, and condition of the patient’s feet. With many different job descriptions and work environments, the practitioner needs to question the patient in regard to safety issues and footwear requirements within their particular workplace. Once the evaluation is complete, a course of treatment and goals are established following a physician’s prescription.
Factors to consider Factors to consider include the following:
Activity level: Does the job description include walking or standing on irregular versus smooth walking surfaces, climbing, and using footoperated equipment? Work environment: Consider the work environment’s effect on the footwear, such as harmful materials (ie, petroleum products, water, dairy products, and chemicals).
E-mail address: [email protected] (T. Colaizzi). 1083-7515/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved. PII: S 1 0 8 3 - 7 5 1 5 ( 0 2 ) 0 0 0 3 4 - 7
404
T. Colaizzi / Foot Ankle Clin N Am 7 (2002) 403–408
Fig. 1. Model of a patient’s foot.
Footwear safety requirements: These include slip resistance; safety toes; metatarsal guards (steel or similar material used as a reinforcement and integral part of the structure of the footwear to protect the foot from impact crush injuries); high-top boots or low-cut oxfords; and governmental-safety guidelines. In the United States these guidelines are established and maintained by the Occupational Safety and Health Administration [2,3].
In the case of the injured worker’s foot, some factors need to be considered when setting realistic goals: maintain support and balance; accommodate fixed deformities, such as hammer toes, overlapped toes, rigid flat feet, claw toes, posttraumatic limited range of motion; and reduce painful pressure. Address each flexible deformity independently to assist in pain relief, at the same time maintaining proper foot position within the shoe and considering walking surface. Once the practitioner establishes goals, the patient is informed how to use and maintain modalities, and how to comply with the physician’s goals. At this point, pedorthic implementation begins. The practitioner must recognize the importance of the shoe’s role. The shoe is the foundation of all pedorthic treatment. The shoe must meet the needs of the patient’s activities, be modifiable if necessary, and be used with either internal or external modifications. At this point, the shoe fit becomes the primary focus. In shoe fitting, the pedorthist considers a few guidelines: shoe shape, shoe fit, and proper shoe closure. Shoe shape is matched to foot shape (Fig. 2). This can be evaluated by first tracing the weight-bearing foot on a piece of paper and visually comparing it to a tracing of the bottom of the shoe. Matching shoe and foot shapes reduces potential risk of pressure, especially with an insensate foot. Shoe fitting considerations include measuring both feet to ensure the larger of the two feet has adequate room, having the patient stand during the fitting process to ensure enough toe space and to check that the widest part of the foot
T. Colaizzi / Foot Ankle Clin N Am 7 (2002) 403–408
405
Fig. 2. Various shoe bottom shapes.
is in the widest part of the shoe, and observing the patient walking in the shoe to make sure it fits the heel area comfortably with minimal slippage. Proper shoe closure, shoelaces, or hook and loop straps are preferred to assist in controlling the foot’s position in the shoe. Additional considerations are the patient’s ability to reach their shoes and adequately secure them. Without a proper fit, the integrity of the case is compromised. This requires a trial fitting when internal modifications are used (ie, foot orthoses and internal shoe modifications [Fig. 3]). In this way all variables are considered, and a combination of the shoe and modality is evaluated for fit. Shoe fit capabilities vary depending on shoe type (ie, dress shoes with less available internal space can diminish the function of the modification or orthotic device). Either a shoe with more available internal room or less modification, or a smaller orthotic may be used as long as the balance of footwear requirement and patient needs are compatible. The same focus is required when using external modifications (ie, rocker-bottoms, wedges, and so forth [Fig. 4]). With the availability of
Fig. 3. Foot orthoses.
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T. Colaizzi / Foot Ankle Clin N Am 7 (2002) 403–408
Fig. 4. (In order from left to right) Negative heel unweights heel. Rocker-bottom with apex posterior to metatarsal area unweights forefoot. Toe-rocker unweights toe tip.
today’s advanced adhesives, external modifications can be adapted to most any footwear without altering the integrity and safety designs of the footwear. The pedorthist who works with adequate experience and knowledge of shoe fitting and has sufficient shoe inventories to conduct trial fittings is clearly best suited to reach the patient’s footwear needs. Common worker injuries often result in partial foot amputation, crush injuries, fractures, and stress fractures. To accommodate a partial foot amputation, the practitioner builds a prosthetic filler (Fig. 5) into the foot orthoses to be used in either a custom-molded or depth shoe (Fig. 6). A rigid rocker-bottom is used to allow the foot to have a smooth heel-strike to toe-off motion with ease. A prosthetic filler is designed to accommodate various amputations; however, they have common goals in treatment, which contribute to providing support and balance. Pedorthic considerations with crush injuries require rigid rocker-bottoms to limit motion and a multidensity foot orthoses to reduce impact. The rocker design often requires adjustment to suit individual needs to reduce pain and increase function. The goal in the pedorthic treatment of stress fractures and fractures is to reduce movement at the site of the fracture. The use of stiff-bottom shoes or rigid-rocker soles reduces movement and harmful forces. Once the practitioner determines the
Fig. 5. Model of partial foot amputation and prosthetic filler.
T. Colaizzi / Foot Ankle Clin N Am 7 (2002) 403–408
407
Fig. 6. Depth shoe (cross section).
needed modalities to suit the injuries, selection of footwear, which meets the requirements of the workplace and also its ability to be modified, must be determined carefully. Often compromises are needed, which sometimes affect the patient’s ability to return to their previous duties. With today’s footwear and material choices, however, these instances are few. Ankle and foot problems in the industrialized setting occasionally present special challenges for the pedorthist. Not only must the footwear help to ameliorate the worker’s underlying musculoskeletal condition but it must do so with constraints imposed by the patient (ie, reasonably appropriate fashion considerations); the employer; and type of employment (ie, slip-resistant soles when working around wet floors, shoe nonconductivity to electrical current, stiffbottom shoes for workers who spend a lot of time on ladders, water-proof footwear in wet environments, and insulated footwear in cold environments). Once the pedorthist completes footwear fabrication and fitting, a gradual break-in period begins next, starting with limited use, gradually increasing to fulltime use. This should include instructions for the patient to consistently examine his or her foot for signs of developing foot problems (ie, irritation, redness, rubbing, balance, instability, or uncomfortable gait). If problems develop, the patient must consult the pedorthist and visit the physician. The patient must consistently inspect all pedorthic footwear for wear and tear. At the first sign of wear and tear, the patient must visit the pedorthist for footwear maintenance. Significant wear negatively affects the footwear’s ability to reach the patient’s needs and goals. Follow-up should include regularly scheduled visits with the pedorthist. The pedorthist works from a physician’s prescription, which includes a diagnosis, modality, and desired goals. The pedorthist’s and the physician’s combined efforts result in the patient’s foot, shoe, shoe modifications, and foot orthoses working together as one unit.
408
T. Colaizzi / Foot Ankle Clin N Am 7 (2002) 403–408
References [1] Taylor EJ, editor. Dorland’s illustrated medical dictionary. 27th edition. Philadelphia, PA: WB Saunders; 1988. [2] Pedorthic Footwear Association. Introduction to pedorthics. Columbia, MD: Pedorthic Footwear Association; 1998. [3] Occupational Safety and Health Administration, US Department of Labor. Available at www. osha.gov.
Pedorthic considerations in the management of the injured worker Ted Colaizzi, CPed Colaizzi Pedorthic Center, 617 Forest Avenue, Pittsburgh, PA 15202, USA
According to the 27th Dorland’s Medical Dictionary, pedorthics is ‘‘the design, manufacture, fit, and modification of shoes and related foot appliances as prescribed for the amelioration of painful or disabling conditions of the foot and limb’’ [1]. Pedorthics uses footwear, including foot orthoses, to help ease foot problems. A certified pedorthist (CPed) works as part of the allied health care team, dispensing footwear to keep people as mobile as possible. Shoes can be customized or modified to fit an individual’s needs; they can also be custommade or handcrafted over a standardized model, called a shoe ‘‘last,’’ or custommolded or handcrafted from a model of the patient’s own foot (Fig. 1). Pedorthic care of the injured worker starts with a complete pedorthic evaluation. The evaluation includes important patient information, such as activity level, work environment, and condition of the patient’s feet. With many different job descriptions and work environments, the practitioner needs to question the patient in regard to safety issues and footwear requirements within their particular workplace. Once the evaluation is complete, a course of treatment and goals are established following a physician’s prescription.
Factors to consider Factors to consider include the following:
Activity level: Does the job description include walking or standing on irregular versus smooth walking surfaces, climbing, and using footoperated equipment? Work environment: Consider the work environment’s effect on the footwear, such as harmful materials (ie, petroleum products, water, dairy products, and chemicals).
E-mail address: [email protected] (T. Colaizzi). 1083-7515/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved. PII: S 1 0 8 3 - 7 5 1 5 ( 0 2 ) 0 0 0 3 4 - 7
404
T. Colaizzi / Foot Ankle Clin N Am 7 (2002) 403–408
Fig. 1. Model of a patient’s foot.
Footwear safety requirements: These include slip resistance; safety toes; metatarsal guards (steel or similar material used as a reinforcement and integral part of the structure of the footwear to protect the foot from impact crush injuries); high-top boots or low-cut oxfords; and governmental-safety guidelines. In the United States these guidelines are established and maintained by the Occupational Safety and Health Administration [2,3].
In the case of the injured worker’s foot, some factors need to be considered when setting realistic goals: maintain support and balance; accommodate fixed deformities, such as hammer toes, overlapped toes, rigid flat feet, claw toes, posttraumatic limited range of motion; and reduce painful pressure. Address each flexible deformity independently to assist in pain relief, at the same time maintaining proper foot position within the shoe and considering walking surface. Once the practitioner establishes goals, the patient is informed how to use and maintain modalities, and how to comply with the physician’s goals. At this point, pedorthic implementation begins. The practitioner must recognize the importance of the shoe’s role. The shoe is the foundation of all pedorthic treatment. The shoe must meet the needs of the patient’s activities, be modifiable if necessary, and be used with either internal or external modifications. At this point, the shoe fit becomes the primary focus. In shoe fitting, the pedorthist considers a few guidelines: shoe shape, shoe fit, and proper shoe closure. Shoe shape is matched to foot shape (Fig. 2). This can be evaluated by first tracing the weight-bearing foot on a piece of paper and visually comparing it to a tracing of the bottom of the shoe. Matching shoe and foot shapes reduces potential risk of pressure, especially with an insensate foot. Shoe fitting considerations include measuring both feet to ensure the larger of the two feet has adequate room, having the patient stand during the fitting process to ensure enough toe space and to check that the widest part of the foot
T. Colaizzi / Foot Ankle Clin N Am 7 (2002) 403–408
405
Fig. 2. Various shoe bottom shapes.
is in the widest part of the shoe, and observing the patient walking in the shoe to make sure it fits the heel area comfortably with minimal slippage. Proper shoe closure, shoelaces, or hook and loop straps are preferred to assist in controlling the foot’s position in the shoe. Additional considerations are the patient’s ability to reach their shoes and adequately secure them. Without a proper fit, the integrity of the case is compromised. This requires a trial fitting when internal modifications are used (ie, foot orthoses and internal shoe modifications [Fig. 3]). In this way all variables are considered, and a combination of the shoe and modality is evaluated for fit. Shoe fit capabilities vary depending on shoe type (ie, dress shoes with less available internal space can diminish the function of the modification or orthotic device). Either a shoe with more available internal room or less modification, or a smaller orthotic may be used as long as the balance of footwear requirement and patient needs are compatible. The same focus is required when using external modifications (ie, rocker-bottoms, wedges, and so forth [Fig. 4]). With the availability of
Fig. 3. Foot orthoses.
406
T. Colaizzi / Foot Ankle Clin N Am 7 (2002) 403–408
Fig. 4. (In order from left to right) Negative heel unweights heel. Rocker-bottom with apex posterior to metatarsal area unweights forefoot. Toe-rocker unweights toe tip.
today’s advanced adhesives, external modifications can be adapted to most any footwear without altering the integrity and safety designs of the footwear. The pedorthist who works with adequate experience and knowledge of shoe fitting and has sufficient shoe inventories to conduct trial fittings is clearly best suited to reach the patient’s footwear needs. Common worker injuries often result in partial foot amputation, crush injuries, fractures, and stress fractures. To accommodate a partial foot amputation, the practitioner builds a prosthetic filler (Fig. 5) into the foot orthoses to be used in either a custom-molded or depth shoe (Fig. 6). A rigid rocker-bottom is used to allow the foot to have a smooth heel-strike to toe-off motion with ease. A prosthetic filler is designed to accommodate various amputations; however, they have common goals in treatment, which contribute to providing support and balance. Pedorthic considerations with crush injuries require rigid rocker-bottoms to limit motion and a multidensity foot orthoses to reduce impact. The rocker design often requires adjustment to suit individual needs to reduce pain and increase function. The goal in the pedorthic treatment of stress fractures and fractures is to reduce movement at the site of the fracture. The use of stiff-bottom shoes or rigid-rocker soles reduces movement and harmful forces. Once the practitioner determines the
Fig. 5. Model of partial foot amputation and prosthetic filler.
T. Colaizzi / Foot Ankle Clin N Am 7 (2002) 403–408
407
Fig. 6. Depth shoe (cross section).
needed modalities to suit the injuries, selection of footwear, which meets the requirements of the workplace and also its ability to be modified, must be determined carefully. Often compromises are needed, which sometimes affect the patient’s ability to return to their previous duties. With today’s footwear and material choices, however, these instances are few. Ankle and foot problems in the industrialized setting occasionally present special challenges for the pedorthist. Not only must the footwear help to ameliorate the worker’s underlying musculoskeletal condition but it must do so with constraints imposed by the patient (ie, reasonably appropriate fashion considerations); the employer; and type of employment (ie, slip-resistant soles when working around wet floors, shoe nonconductivity to electrical current, stiffbottom shoes for workers who spend a lot of time on ladders, water-proof footwear in wet environments, and insulated footwear in cold environments). Once the pedorthist completes footwear fabrication and fitting, a gradual break-in period begins next, starting with limited use, gradually increasing to fulltime use. This should include instructions for the patient to consistently examine his or her foot for signs of developing foot problems (ie, irritation, redness, rubbing, balance, instability, or uncomfortable gait). If problems develop, the patient must consult the pedorthist and visit the physician. The patient must consistently inspect all pedorthic footwear for wear and tear. At the first sign of wear and tear, the patient must visit the pedorthist for footwear maintenance. Significant wear negatively affects the footwear’s ability to reach the patient’s needs and goals. Follow-up should include regularly scheduled visits with the pedorthist. The pedorthist works from a physician’s prescription, which includes a diagnosis, modality, and desired goals. The pedorthist’s and the physician’s combined efforts result in the patient’s foot, shoe, shoe modifications, and foot orthoses working together as one unit.
408
T. Colaizzi / Foot Ankle Clin N Am 7 (2002) 403–408
References [1] Taylor EJ, editor. Dorland’s illustrated medical dictionary. 27th edition. Philadelphia, PA: WB Saunders; 1988. [2] Pedorthic Footwear Association. Introduction to pedorthics. Columbia, MD: Pedorthic Footwear Association; 1998. [3] Occupational Safety and Health Administration, US Department of Labor. Available at www. osha.gov.