Pedorthics - Pedorthic Association of Canada

Transcription

A Periodical of the Pedorthic Association of Canada
Quarterly
Summer 2010
Pedorthics
Focus on Footwear...
In this Issue...
President’s Message 3
Board Updates 4
Footwear Modifications
6
Course Review: Biomechanical and
Clinical Factors Associated with
Lower Extremity Injuries
7
Member Profile: Ryan Robinson 8
Member Profile: Nancy Kelly 9
HST Information
10
CPC Update
11
Rock n’ Roll Shoes: Unstable Trends
in Footwear Design
12
A Runner’s Footwear Wear Pattern:
Observation and Interpretation
14
Since When Did Running in Shoes
Lead to Knee OA?
16
Shoe Anatomy 19
The newest Mississauga clinic located at 2000 Credit
Valley Road has seen tremendous success since it opened
it’s doors on March 1, 2010.
A special “Thank You” goes out to PAC for their help
in getting the word out to it’s members.
Career Opportunities
With ten clinics and growing, Walking Mobility Clinics is looking
for Pedorthists who would enjoy managing a new corporate clinic
or owning a Walking Mobility Clinic of their own.
Our focus is clinically based (not retail based) and staffed with
a dynamic team of Pedorthists, Physicians and Chiropodists.
If you are interested in joining our comprehensive team
approach and would like to discuss a new opportunity
with Walking Mobility Clinics, please contact:
Ryan Robinson, Pedorthic Director
Walking Mobility Clinics
ryan.robinson@walkingmobilityclinics.com
www.walkingmobilityclinics.com
President’s Message
Summer 2010
By Graham Archer,
C. Ped Tech (C), C. Ped (C)
As I am writing this the Chicago Blackhawks are just advancing to the
Stanley Cup final after rolling through Nashville, my beloved Canucks
and San Jose. It has been a big year for hockey when you pair the
Stanley Cup with the Olympic tournament and it has been difficult to
not notice that the youth is taking over this game. Toews, Doughty,
Crosby, Ovechkin and many other young superstars are shaping the
future of hockey.
I can’t help but think how similar this is to pedorthics in Canada. Over
50 per cent of our membership is under 40 years old and 40 per cent of
those are under 30. This is likely the youngest our profession has ever
been. Thirty-two per cent of our members joining since 2008 have
come directly out of the UWO program. The future of our profession
revolves around developing young energetic members and providing
them the opportunity to get involved in career events, professional
development, symposiums and conferences and ultimately the PAC
and CPC professional boards.
In the company that I work for and region that I work in, I am
witnessing firsthand the transformation of pedorthics with the
younger generation. Older ideas and thoughts are being questioned;
new ideas are coming forward, both in pedorthics and in business
practices. The more we harness this energy, the stronger this
profession becomes.
There are ways that all of can continue to attract and develop new
members: train new pedorthists in an internship program, volunteer
your clinic to accept new UWO practicum students, use your contacts
at your local university to spread the word about pedorthics to
undergraduate students, volunteer to set up a booth at a local career
fair, contribute to the futures fund to directly help in marketing
pedorthics across the country, volunteer for a committee or nominate
someone for the PAC or CPC boards.
I am very proud to say that I have done all of these and not only has it
helped attract new members it also allowed me to develop personally
and professionally.
I am looking forward to seeing us grow and become stronger
during my term as president. Pedorthics is a great profession and
the future looks bright. Please do not hesitate to contact me at
garcher@kintec.net.
The Pedorthic Association of Canada would
like to thank all of the members who have
contributed to the 2010 Pedorthic Futures
Fund. With your support the Pedorthic
Futures Fund is on its way towards our goal of
$35,000. At the annual symposium in Ottawa
we raised more than $20,000! The Pedorthic
Futures Fund is vital to helping us continue our
marketing initiatives to increase the profile of
Pedorthics in Canada.
Thank to the following contributors as well
as all those who have chosen to remain
anonymous. If you would like to contribute
to the Pedorthic Futures Fund, please
contact the PAC office at 1-888-268-4404, or
info@pedorthic.ca.
BioPed Bedford, Nova Scotia
BioPed Stoney Creek/BioPed Burlington
Meghann Brunet, C. Ped Tech (C), C. Ped (C)
Nick Caravaggio
Deny Dallaire, C. Ped (C)
Michael Domanko
Kootenay Pedorthic Clinic
Jane Laycock, C. Ped (C)
Paul Lucas, C. Ped (C)
Michael Ondevilla, C. Ped Tech (C), C. Ped (C),
BioPed Etobicoke
Frank Pozzuoli, C. Ped (C), CO
Progressive Step
Aditi Rajendra, C. Ped (C), Custom Orthotic
Design Group Mississauga
Brian Scharfstein, C. Ped (C)
Minal Sheth, C. Ped (C) – BioPed Markham
3
Quarterly
Pedorthics
Board Updates
Communications
Chair – Linda Deschamps, The communications committee
is continuing to work hard to
C. Ped (C)
provide our membership with
Vice-Chair – Nancy Kelly,
more scientific and research based
articles with Pedorthics Quarterly.
We are also working to include information which is not only
clinically relevant but some technical/lab-oriented articles as well. As
you have probably noticed, we are trying to pick a specific topic for
each edition. This summer edition centres on footwear and our fall
edition topic will be “casting”.
The committee members are always looking to recruit PAC members
to contribute articles to PQ. In this edition we are excited to be
including articles submitted by students in the UWO Pedorthics
program. Thank you to Valerie Simpson and Michele Peters.
If you are interested in contributing to PQ, please contact Linda
Deschamps at ldeschamps000@sympatico.ca.
Education
Chair – Lisa Irish,
The main goal of the Education
committee is to support the
Diploma in Pedorthics program at
Vice-Chair – Ryan Robinson,
the University of Western Ontario
(uwo.ca/cstudies/pedorthics).
That involves reviewing course content, supporting instructors and
promoting the program to prospective students. In order to meet the
demand for certified pedorthists we must continue to aggressively
promote the Diploma in Pedorthics program at UWO. One of the
main ways of promoting the program at Western is through career
fairs at universities across Canada. Western attends a number of
fairs to promote Professional Development programs including the
Diploma in Pedorthics independently and also in conjunction with
PAC representatives (that would be you!). The education committee
recruits members to attend these career fairs so that prospective
students have active pedorthists that can give them a better
understanding of what a career in pedorthics involves.
If you are interested in manning a booth at a career fair to
encourage students to pursue a career in pedorthics then contact
the education committee and we will keep you on our list for
opportunities in your area.
We are always looking for committed certified pedorthists to act
as practicum supervisors for the pedorthic program. It is through
supervised placements that pedorthic students truly learn to apply
their course work to real people. It is so important that we have
excellent placement opportunities for students so they are well
prepared to enter the pedorthic industry upon graduation. If you
feel you could supervise a student for a placement opportunity then
contact UWO for information on the necessary requirements for a
placement location and supervisor.
C. Ped (C)
4
Summer 2010
The following chart shows the enrolment history for the Diploma in
Pedorthics. Numbers for this coming September on not yet available
because it is too early to determine exact numbers.
UWO Diploma in Pedorthics – Enrollment History
2005 2006 2007 2008 2009 2010
Applicants
21
19
24
21
29
27
Accepted
20
15
20
18
25
N/A
Enrolled
8
13
13
13
15
8/0
12/1
12/1
8
12
12
Full-time/Part-time
Graduates
12/1 13/2*
13
13**
* 3 withdrew after classes began.
** Expected graduation pending successful completion of all diploma requirements.
Ethics
Chair – Vanessa Carnovale, The ethics committee is pleased
to report that there are no new
matters before the PAC ethics
Vice-Chair – Nancy Kelly,
committee at this time. Please
remember complaints about
certified members are handled by the CPC.
Insurance and Government Relations
Chair – Brad Gibbs, On May 4, 5 and 6, PAC Executive Director
Jonathan Strauss, IGR Chair Brad Gibbs
C. Ped (C)
and Deny Dellaire represented PAC at the
annual Canadian Life and Health Insurance Association Conference in
Montreal. The CLHIA is a voluntary trade association that represents
the collective interests of its member life and health insurers.
Deny delivered a French language PowerPoint presentation of “An
Introduction to Pedorthics” to a group of claims representatives that
was well received. This was the first time we as an organization had
delivered a French language presentation. Well done Deny!
The opportunity allowed us to strengthen existing relationships with
members of the Health Claims side of the insurance industry, and
cultivated new relationships with the president of The Canadian
Kinesiology Alliance, and the Quebec equivalent of PAC – AOPQ
(L’Association des orthésistes et des prothésistes du Québec),
with promising dialogue on membership and member designation
between our two organizations.
With consultation from our law firm, we developed an information
memorandum with respect to the implementation of the HST in both
British Columbia and Ontario. This was distributed by email and is
included in this edition of Pedorthics Quarterly.
Membership
Chair – Ryan Robinson, Before we can move forward, I think it is always wise to know
where we’ve been. As most of us know, in the “grand scheme of
things” our profession is quite new. However, we are growing
at a very healthy rate. This is best evidenced by the fact that our membership has grown an
amazing 100 per cent between 2002 and 2009.
Below is a brief summary of our membership categories over the past 3 years.
2007
2008
2009
Certified Practicing Members
365
413
441
Candidate Members
64
71
67
15
21
16
4
3
9
17
16
22
465
524
555
(eg. those about to write exams)
Non-Practicing Members
(eg. Allied health care professionals)
On-Leave
(eg. Maternity leave, return to formal education, etc.)
Sustaining Members
(eg. Suppliers or affiliated companies that support the profession)
TOTALS
As the director in charge of membership it is clear that my mandate is to increase all forms of
membership. A strong membership provides a number of benefits to us all, including better
lobbying power, better funding for PAC sponsored events, better funding for profession
marketing, potential for more research and many more.
Simply put, there is strength in numbers and I will be working diligently to expand our
membership numbers in order to achieve the goals that I have set for the membership portfolio.
Professional Development
We wish to thank all members that have recently
Chair – Patrick Bergevin,
applied to be part of the committee. We are currently
reviewing our committee membership to ensure
Vice-chair – Vanessa Carnovale,
representation from several provinces and are setting
our goals for the upcoming term. We are reviewing
the themes from past PD seminars and annual conferences, as well as valuable survey results and
suggestions, before defining next year’s two events. We want to assure you, the member, that
your feedback through our online surveys is being reviewed by the committee and that we will
endeavour to include topics that received a high level of interest.
The main goal of the PD committee is to increase the number of members that can benefit
from professional development events; thinking beyond the box may help us achieve this goal
in unprecedented ways. We hope to increase attendance at our semi-annual in-person events by
offering innovative seminar topics and reputable speakers. However, for members who cannot
travel to such events, the PD committee will look at new techniques to reach a higher number
of members through technological advancements. More information will be provided as these
techniques are explored.
Finally, a western Calgary PD event was presented by Dr. Read Ferber on June 12th. Dr. Ferber is
an enthusiastic and highly motivating individual who presents the latest in study results, thanks
to his role with the “running injury clinic” at the University of Calgary.
Help Us Be Green!
If you would like to receive Pedorthics
Quarterly electronically instead of
the paper version, contact the PAC
office at info@pedorthic.ca.
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.
Publisher Information
Pedorthics Quarterly
Pedorthics Quarterly is published by:
Pedorthic Association of Canada
Suite 503 – 386 Broadway Avenue
Winnipeg, Manitoba R3C 3R6
Toll Free: 1-888-268-4404
Fax: (204) 947-9767
Email: info@pedorthic.ca
Printed by Kendrick Printing ISBN #1194-305X
Communications Committee Co-Chairs
Linda Deschamps, C. Ped (C)
Nancy Kelly, C. Ped Tech (C), C. Ped (C)
Doug Benoit, C. Ped Tech (C)
Grace Boutilier, C. Ped Tech (C), C. Ped (C)
Jim Pattison, C. Ped (C)
Michael Ryan, C. Ped Tech (C), 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 ©2010 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.
5
Quarterly
Pedorthics
Footwear Modifications
Edited from PEDS6013 paper
When applied correctly, footwear
modifications can produce significant
results. These can be used to aid in the transfer of forces, off-loading
at-risk or sensitive areas of the foot, rebalancing or realigning the
musculoskeletal system, accommodating fixed deformities and
motion control (Kennedy, 2006). The following will discuss several
different footwear modifications and how they can be applied to your
practice.
By Michele Peters
Flare
This is an excellent footwear modification for ankle instability of a
varus deformity. A flare is often used for patients with peroneal
paralysis and atrophy, as it provides ground reactive forces with
a longer lever arm for pivoting at the heel at heel strike (Michaud,
1997), preventing the foot from rolling over as it decreases stress on
the heel and ankle, either laterally (with a lateral flare) or medially
(with a medial flare). As flares allow for more surface contact, the
overall pressure on the foot in reduced. Flares are often combined
with heel wedges to control greater degrees of inversion or eversion.
Wedges
These modify the angle of the rearfoot and/or forefoot of the sole of
the shoe. These are often recommended for peroneal paralysis in CVA
and polio patients. Wedges can accommodate for a rigid deformity or
correct a flexible deformity. A medial wedge is advisable for hyperpronation, while a lateral anterior wedge will transfer pressure away
from the fifth metatarsal shaft and induce a pronatory moment during
midstance. A four millimetre wedge is a typical height. Any value
higher would tend to cause the foot to slide down the incline (Tyrrell,
Carter, 2009).
Heel counters
Heel counters work well in conjunction with the orthoses, by applying
force in a cupping motion to the calcaneus and talar head as the foot
begins to pronate (Fuller, 1994) or abnormally supinate. The heel
counter can be modified internally by peeling back or lifting up the
lining of the shoe’s hind quarter and reinforcing and/or extending
its strength with Renoflex or Celastik, medially or laterally. The heel
counter can also be modified externally with fibreglass, which may give
more control but is less aesthetically pleasing (Tyrrell, Carter, 2009).
Butresses or outriggers
This is an external modification made to the midsole to control
instability during midstance. This is done by widening the base of
support and reinforcing the upper, either medially (for abnormal
pronation) or laterally (for abnormal supination). Layers of firm EVA
or crepe material, 50 durometre and up, are added from the ground
up in the shape of a scaphoid pad and extended above the welt line
onto the quarter of the shoe.
6
Summer 2010
Rocker soles
This is one of the most common modifications used to address sagittal
plane abnormalities. Rocker soles are created by adding light weight,
rigid material, such as EVA/crepe to the midsole. Rocker soles have
a pivotal point strategically placed, from which the foot rolls forward
(Tyrrell, Carter, 2009), proximal to the point of pressure. Rearfoot
rockers minimize the need for motion at the ankle joint, decelerating
the limb during heel-strike and preventing abrupt plantarflexion “slap”
into full foot loading, reducing shock significantly (Valmassy, 1996).
External heel elevation
This is used to accommodate leg length discrepancies and equinous
deformities. An addition of lightweight, yet firm material is added to
the midsole of the shoe. Consideration should be given to patients
with forefoot deformities, as adding an elevation will increase
pressure on the forefoot. To assist in forward progression, a rocker
can be added to the elevation.
Pedorthists must also remember that patients with drop foot will have
difficulty dorsiflexing the foot with additional weight added to the
shoe.
Shuffle plates or toe slips
These are permanent, external modifications made to the forefoot
of the sole of the shoe. An addition of smoother, more slippery
material is added to prevent tripping and is ideal for patients with a
drop foot gait. This is particularly helpful when walking in a carpeted
environment (Steenwyk, 2010).
References
Beth Rose, B.A., B.Sc. (O.T.), Lincolnshire Post-Polio Library [A Look
at Feet] for people with the late effects of polio.mht
Casella, M. Prescription Shoes for Foot Pathology,
www.podiatrym.com Podiatry Management 2005:10
Fuller EA. “A review of the biomechanics of shoes”.
Clin Podiatry Med Surg 1994 Apr; 11(2):241-58.
Janisse D. Janisse E., “A Guide to Conservative Stabilization of the
Neuromuscular Foot”, Podiatry Today, 2008; 11(Vol) 11
Kennedy S., If the Shoe Fits… Pedorthic Modifications for Optimal
Function The O&P EDGE oandp_com.mht, 2006:4(2)
Lin SS., Sabharwal S., Bibbo C. Orthotic and bracing principles in
neuromuscular foot and ankle problems. Foot Ankle Clin 2000 June
5(2)235-64
Michaud TC. “Foot Orthoses and Other Forms of Conservative Foot
Care, Massachusetts 1997:227
Nicolas S., Selecting Appropriate AFO’s Key Consideration and
Modifications 2003 Oct Vol 16:10,
www.podiatrytoday.com/article/2008 Gregory T C Rehabilitation
Management of Neuromuscular Disease Contributor Information
and Disclosures 2009:7
www.pedorthic.ca/files/medua/14.pdf Position Statement on
Custom-Made Footwear, Orthopedic Footwear, and Sandals
10/03/2009
Ramcharitar SI, Koslow P, Simpson DM, Clin Podiatr Med Surg.
Lower extremity manifestations of neuromuscular diseases.
Clin Podiatr Med Surg. 1998 Oct; 15(4):705-37, vi-vii.
Steenwyk. Shoe Modifications: Steenwyk Custom Shoes and
Orthotics. 2010 http://www.steenwyk,com/mod.php
Tyrrell W., Carter G., Therapeutic Footwear, A Comprehensive
Guide. Churchill Livingston 2009:102-104; 133-136
Valmassy, R. Clinical Biomechanics of the Lowe Extremities, Mosby
Inc. 1996:365-365
there are motions they expect to see during the gait analysis. Medial
heel whip comes from weak hip external rotator muscles and tight
hip internal rotator muscles. A medial heel whip increases twisting
forces when running. A bilateral genu valgum increases demand on
the tibialis posterior by forcing the foot into a hip-induced pronation.
A Trendelenburg Sign is an indication of weak hip stabilizers.
Treatment programs include a progressive strength routine and a
stretching routine.
Course Review: Biomechanical and
Clinical Factors Associated with Lower
Extremity Injuries
By Jody Simpson, Dr. Reed Ferber and his team at the Running
Injury Clinic at the University of Calgary
C. Ped (C)
are conducting world-class research into
the understanding of the main factors that contribute to running
injuries. Ferber’s research is multi-dimensional taking into account,
3D biomechanics, strength, flexibility and anatomical alignment.
Findings from Ferber’s research have indicated that hip strength is a
key factor in injury rehabilitation. As pedorthists, we traditionally take
the approach of looking from the foot up to treat lower limb injuries.
Ferber gives us a different perspective. Rather than looking from foot
up, he suggests looking from hips down.
Research Associate Melissa Rabbito C Ped (C), presented her Master’s
thesis on Posterior Tibial Tendon Dysfunction (PTTD). The purpose
of the study was to investigate the relationship between strength and
structural mechanics in a stage 1 PTTD subject, in comparison with
healthy individuals. The PTTD group did show a difference in static
foot structure, an increase in rear foot eversion, but did not show
decreased tibialis posterior strength.
The Running Injury Clinic has the world’s largest database to
understand the main factors related to running injuries. We were
able to get into the lab to go through an assessment on a partner.
We investigated muscular strength of the hip external rotators, hip
flexors and hip abductors using the Manual Muscle Testing Scale. We
looked at foot measurements, rear foot eversion, mid foot position,
foot mobility, standing rear foot, tibialis posterior, tibialis anterior
and peroneal muscles. Muscular flexibility of internal hip rotation and
external hip rotation were also highlighted. Gait observations looking
at heel whip, genu valgum, trendelenberg gait, excessive pronation
and cross-over gait were also observed.
Clinic Director and Ph.D. Candidate Karen Kendall spoke to us about
the Running Injury Clinic’s gait analysis. After gathering results from
the muscle strength tests, foot measurements and hip flexibility,
A big thank you goes out to Dr. Reed Ferber, Karen Kendall,
Melissa Rabbito, Tori Orosz and the Running Injury Clinic
for hosting this informative, cutting edge course. For more
information about the Running Injury Clinic at the University of
Calgary visit www.runninginjuryclinic.com.
BioPed Windsor Seeks
Pedorthic Clinician to join our team!
The candidate should be a Canadian certified pedorthist or
kinesiology graduate who wishes to pursue certification in
pedorthics. A very busy and diverse clinic, we have a full fabrication
laboratory and routinely see a full spectrum of conditions.
Excellent pay, benefits and possibility of ownership for the right
candidate. For more information, please visit our career posting on the PAC website.
Please send your resume in confidence to:
Frank Pozzuoli C. Ped (C), CO
Fax. 519. 973.1246 (9-3 hours only)
fpozzuoli@bioped.com
7
Quarterly
Pedorthics
Summer 2010
Member Profile
While Nancy Kelly’s career path began like
so many other pedorthists, it was a cloudy
moment in time whose silver lining showed
her the way into the industry.
From the beginning, Nancy had the inclination
to work with people and help them improve
their lives. This, as she explains, began with
the path she started at Dalhousie University,
where, after graduation, she had an encounter
with orthotics.
Nancy Kelly
C. Ped Tech (C), C. Ped (C) “In my Kinesiology career I had the
opportunity to work with a pedorthist and
got exposed to shoe-fitting and orthotics a little bit,” she says.
That may have been her initial exposure to pedorthics, but an unfortunate
turn of events resulted in Nancy getting experience very first hand. After
suffering a knee injury, Nancy’s physiotherapist sent her to a pedorthist,
an encounter that would end up not only helping her make her final
decision for her career choice, but has served her well in relating to
people she helps today.
“As a clinician, I encounter a lot of, ‘well it’s my knee, what does that have to
do with what’s going on with my foot?’ Well, I was shocked at the difference
it made for me, so it’s nice to share some personal experiences with patients
when they’re asking a lot of different things,” she says. “Just to have that
firsthand experience – being an orthotic wearer – you get a bit of a different
perspective, having been on the opposite side, to be able to understand the
difficulties when you’re going through the history like that.”
Also part of her decision to move to pedorthics was an interest to pursue
a career beyond her original intentions.
“I wanted to further my education and do something besides exercise
counseling and pedorthics seemed like the natural way to go,” she adds.
“Once I started learning about it, it sounded incredibly interesting.”
Today, Nancy is one of the top pedorthists in Nova Scotia. Though
she’s based in Halifax, Nancy also spends time in clinics throughout the
Maritime province.
“The company I work with has, over the last year, expanded quite
extensively, and I’m the only pedorthist,” she explains, “so I go into areas
where there aren’t a lot of pedorthic clinicians.”
This duality has led to a unique position for Nancy, where she experiences
very different patient groups on a regular basis.
“The dynamic is interesting when you go into these small places from
working in downtown Halifax,” she explains. “There’s quite a difference
in the small towns and challenges in terms of availability of appropriate
footwear in some of those places. To recommend to somebody to drive
two hours to get a decent pair of shoes isn’t always realistic, so it (the job)
is helping to address some of those challenges as well – finding good
footwear for the different demographics. Some of the socio-economic
demographics in those communities can be different.”
The Nova Scotia native is an avid swimmer and loves being near the
water, which has been one of the primary reasons for her staying in the
Maritimes throughout her life.
“I like the east coast, I can’t imagine not being here,” Nancy says proudly.
“I’ve lived my whole life on the east coast and I can’t imagine living in
central Canada, away from the ocean. I have that need.”
Aon is proud to be the broker
administering the insurance
program for the members of
the Padorthic Association of
Canada including:
• Professional Liability Coverage
• Clinic Coverage
Your insurance renewal date is
June 1, 2010
Please contact us if you have
not yet received your renewal
package
or
If you are a new member
interested in beneting from the
PAC group insurance, we will
be more than happy to provide
you with additional information.
8
group.programs@aon.ca
Aon
1525 Carling Avenue, Suite 710
Ottawa, Ontario K1Z 8R9
Tel: 613.792.4874
Toll Free: 1.800.267.9364
Fax: 613.722.2570
Member Profile
Ryan Robinson
For Ryan Robinson, the progression to being a
pedorthist wasn’t a sure thing.
Initially, he began his academic career simply by
taking a Kinesiology degree at McMaster University.
He remarks that the campus was a beautiful facility
and denotes that even from the beginning, his initial
studies were just a path to his next studies.
“Kinesiology was a really good stepping-stone degree,”
he says.
So why McMaster, if Kin wasn’t a destination diploma?
“I heard nothing but good things,” he says, while also
noting that it was a beautiful campus that was within
an hour of being home.
From there, however, he wasn’t sure where his life would take him next. He
pondered focusing in on physiotherapy and had also contemplated a career in
chiropractics. Yet it was pedorthics that lured the Georgetown native and he
hasn’t looked back.
Like other pedorthists, Ryan first gained knowledge of pedorthics from a personal
encounter with the industry. While at McMaster, Ryan competed in rugby and,
while playing, began wearing orthotics.
After he finished his studies, Ryan began working for his uncle, importing and
exporting steel, as well as gel soles. It was here that entrepreneurship grabbed
hold of Ryan and he began to think of business opportunities relating to
orthotics, initially considering going to mass market.
“[I thought] maybe I could use a bit of leverage at Sport Chek,” he recalls.
Instead of pursuing this direction, however, Ryan chose to go directly into
specialty outlets. He approached Bio Ped, who, in turn asked Ryan to work for
them. As it turned out, the offer would lead to his ultimate career destination.
In 1997, along with partners Dr. Leslie Goldenberg, Sherman Jones and Chris
Rich, Ryan founded Walking Mobility, a network of clinics that today spans 10
Ontario cities, including several locations in the Greater Toronto Area. Ryan and
his family would eventually settle in Barrie where Ryan helped start a clinic in
2005. Ryan describes the reason behind establishing himself and his family in the
town as simply being “a good fit for us.”
Since the founding of Walking Mobility, some of his partners have moved on, but
Ryan has stayed on. He sold most of his shares in the company, staying on with
the ownership group as a minority partner.
Today, Ryan is still the Pedorthic Director for Walking Mobility’s Barrie location.
Dr. Goldenberg, one of the co-founders, works with Ryan today, along with
registered nurse Teresa Richter. He enjoys the flexibility that the clinic offers
him, allowing him the opportunity to also be a ski instructor, one of his favourite
athletic pursuits. He comments that he’s always had an interest in skiing, and
describes it as a “great family sport.”
Outside of work, Ryan is very active with his family, consisting of wife Colleen
and sons Gavin (eight) and Nathan (six). Robinson comments that his boys are
very active, and he maintains a lifestyle so that he can be a big part of their lives,
coaching their hockey teams.
9
Quarterly
Pedorthics
HST Information
Effective July 1, 2010, the provinces of British Columbia and Ontario
will be implementing the federally administered harmonized sales
tax (HST). As the transition to the HST system will inevitably cause a
certain level of confusion and misunderstanding, we provide to you
the following basic introduction and illustration of the key features
surrounding the new HST system. The following information, which
relates specifically to the implementation of the HST system in Ontario
and British Columbia, is for your general consideration only and is not
meant to replace proper advice from your lawyer or accountant.
In general, HST will be applied and administered by the Canada
Revenue Agency (CRA) in a similar fashion to the federal Goods and
Services Tax (GST).
Essentially, by using a value-added tax system such as the HST,
businesses may receive input tax credits to offset the sales tax
they originally pay, when they in turn sell their products to other
purchasers. This results in a system where, unlike the current system
based on the RST, there should be no unseen taxes embedded in
each successive purchase price (which would normally be passed on
to subsequent purchasers).
Effective July 1, 2010, the separate payment of provincial RST
and federal GST will be replaced by a single HST payment. Any
transactions which previously required the payment of RST and GST
will now require the payment of HST.
The introduction of the HST system will not affect the tax treatment
of orthoses and other prescribed medical devices, including
modifications to footwear, and custom footwear. These items remain
non-taxable with a prescription from a medical practitioner.
The introduction of the HST now means you will only be required to
file one form for HST (as opposed to forms for both RST and GST)
and make one payment. In addition, there will now be a centralized
point of contact for audits, appeals and taxpayer services. All these
functions will now be administered by the CRA.
For your information we have reproduced the following guidelines
that can be found at http://www.rev.gov.on.ca/en/taxchange/pdf/
needtoknow.pdf. This is only a general guide and should not replace
the advice of your lawyer or accountant. Please note that the HST
rates set out below are for Ontario HST purposes only. A discussion of
the applicable rates for HST in British Columbia follows the bulleted
points reproduced below.
The HST is basically the GST with a provincial component added to
arrive at a 13% rate. If no GST applies now, no HST will apply after
July 1, 2010. Provincial point of sale rebates mean that selected goods
will only be taxed at 5%.
If you are already registered for GST, no further registration is
required. If you are not required to register for GST, you do not need
to register for HST.
10
Summer 2010
Your HST reporting period will be the same as your GST reporting
period. You will report both GST and HST charged and collected, and
claim input tax credits and rebates in much the same way you have
been for GST.
You should modify accounting, billing and invoicing systems, cash
register and point of sale systems, including web interfaces and
automatic payments, to switch to HST and remove RST. You should
also ensure budgets remove the 8% RST cost from purchases after
July 1, 2010 in accordance with the transitional rules. You should also
update taxable benefit calculations.
Consult the transitional rules for transactions straddling the July 1,
2010 date. Ensure you charge HST, as appropriate, on any billings on
or after May 1, 2010 for taxable goods, services or intangible property
to be supplied after July 1, 2010. Familiarize yourself with the place
of supply rules and the temporary restrictions on input tax credits.
Assess the impact of HST on budget and business plans to account
for lower costs and shifts in business purchasing. Evaluate pricing
strategies and scrutinize supplier quotes to ensure tax savings are
passed on.
Your final RST return is due on or before July 23, 2010. Supplemental
returns will be available for reporting RST amounts collected after July
1, 2010.
Although the above information was prepared by the government of
Ontario, it is generally applicable to HST in British Columbia as well.
One significant difference, however, lies in the HST rates applied in
each province. It is important to note that in British Columbia, HST
will be applied at the combined rate of 12% (comprised of a 5%
federal portion and a 7% provincial portion) compared to a combined
rate of 13% in Ontario (comprised of a 5% federal portion and an 8%
provincial portion). In this light, you should ensure budgets remove
the 7% RST cost from purchases after July 1, 2010 in accordance with
the transitional rules for HST in British Columbia.
When consulting a lawyer or accountant, please ensure you contact
an individual familiar with the laws of the specific province in which
the HST will be assessed.
In Ontario, to learn more about how your business will be affected by
the new HST, you can visit http://www.rev.gov.on.ca/en/taxchange/
index.html or call 1-800-337-7222 (teletypewriter (TTY) 1 800
263-7776).
In British Columbia, to learn more about how your business will be
affected by the new HST, you can visit http://hst.blog.gov.bc.ca or call
1-877-388-4440.
In addition, whether your business is in Ontario or British Columbia,
you may wish to view the CRA’s website at http://www.cra-arc.gc.ca/
harmonization or consider attending one of their free information
seminars designed to assist businesses in transitioning to the new
HST system.
Thank you
The College of Pedorthics of Canada would like to recognize and thank members who took part in the examination process by acting as proctors
over the past year. Our appreciation to the volunteer work done by these individuals cannot be overstated.
If you are interested in volunteering as a proctor, please contact The CPC office at (866) 891-4354 or by email to info@cpedcs.ca. We are always
seeking new individuals that want to get involved; all training will be provided to you.
Graham Archer – Kintec Footlabs
Jasmine Basner – BioPed Footcare Centre
Ingrid Beam – Comfoot & Joy Foot Orthotics
Patrick Bergevin – Orthotics in Motion
Grace Boutilier – Paris Orthotics
Fleur Brouwers
Lana Brooks – Paris Orthotics
Tim Carr – Arthritis and Injury Care Centre
Ryan Chang – Kintec Footlabs
Tony Conrad – BioPed Footcare Centre
Janelle Coultes – BioPed Footcare Centre
Tania DeBenedetti – BioPed Footcare Centre
Colin Dombroski – TDG
Mélanie Gagné – BioPed Footcare Centre
Roy Gishen – BioPed Footcare Centre
Julie Giroux – Women’s College Hospital
Sandra Gullion – D-Feet Pain Orthotics
Lisa Hickman – BioPed Footcare Centre
Milan Hudec – Feet First Orthotics Ltd.
Werner Lau – Orthotics in Motion
Derek Lawton – BioPed Footcare Centre
Mike Neugebauer – Paris Orthotics
Jonathan Nghiem – BioPed Footcare Centre
Nikki MacGillivary – Body N’ Sole Orthopaedic & Sports Rehab
Heather Macpherson – FootHealth Centre
Angela Marasco
Jaimie McVean – Foot Solutions & Women’s College Hospital
Julie Munday – Sole Decisions
Ashley Murray
Mike Ondevilla – BioPed Footcare Centre
Martha Paris – Paris Orthotics
Smruti Paymaster – BioPed Footcare Centre
Nevin Pettyjohn – Queen Alexandra Centre for Children’s Health
Lauren Phillion –Foot Worx
Andrea Putré-Ondevilla – BioPed Footcare Centre
Melissa Rabbito
Fareen Samji
Christy Shantz – Shantz Orthotic Solutions Inc.
Jon Shepherd – Kintec Footlabs
Minal Sheth – BioPed Footcare Centre
Lyndsey Stewart – The Naturopathic and Complimentary Care Centre
Richard Stover
Noelle Trotter – West Coast Pedorthics
Jody Weightman – Paris Orthotics
Connie White – BioPed Footcare Centre
Dean Woodcock – BioPed Footcare Centre
Deanna Zelinka – FootHealth Centre
Congratulations
The College of Pedorthics of Canada would like to congratulate the following individuals who recently passed their certification examinations:
Certified Pedorthic Technician
(Canada)
Davis DesRochers, Kelowna, BC
Sara John, Brampton, ON
Daniel Marquardt, Vancouver, BC
Joefred Tenoso, Markham, ON
Alan Wong, Richmond, BC
Certified Pedorthist (Canada)
Christine Chandler, Brandon, MB
Angela Craparotta, Vaughan, ON
Shawn Duench, Waterloo, ON
Jennifer Johnstone, London, ON
Megan Kitchen, Newmarket, ON
Douglas Lai, Vancouver, BC
Peter Morcom, Maple Ridge, BC
Ian Morgan, St. John’s, NL
Jody Simpson, Calgary, AB
Jameson Smith, Langley, BC
Rajiv Vase, Surrey, BC
11
Quarterly
Pedorthics
Rock n’ Roll Shoe School:
Unstable Trends in Footwear Design
MBT, Skechers, Reebok, Fitflops. Over the
past few years, footwear companies have been
developing shoes featuring attributes once
only seen in custom shoe modifications. Commonly marketed as fitness
footwear, they are also known as toning shoes, antigravity or physiological
footwear and anti-shoes.
By Doug Benoit,
C. Ped Tech (C),
Recent trends have shown a growing demand for these products in a
constantly evolving footwear market. You may be familiar with Earth shoes,
created in the 1950’s, with a negative heel designed to distribute weight
to the rearfoot. Past and present, the principles involved in these types
of footwear have been utilized by pedorthists for their patients. However,
questions may arise when these are mass marketed to the general public,
some of which may be our very own patients. These trendy designs may
benefit someone with relatively healthy feet as an addition to their fitness
regimen, but are they ideal for everyone?
Claims and marketing
Proclaimed benefits from wearing these shoes differ as much as the designs.
They are all based around the concept of creating an unstable platform for
the foot and, in effect, altering gait. This creates a wider range of dynamic
motion and causes muscles to adapt by engaging in different ways. Over
time these actions can promote blood flow in the lower extremities and
strengthen a variety of muscle groups.
This also alters a person’s sense of proprioception, or their internal
perception of the ground below them as they walk. (Proprioception,
unlike the sense of balance (equilibrioception) is not associated with fluid
in the inner ear, but rather the sense of the orientation of one’s limbs in
space. Think: the roadside drunk test when a driver is asked to touch his
nose with his eyes closed or how you can walk or breathe without thinking
about it.)
When the orthopaedic footwear store I worked at first started selling MBTs
(Massai Barefoot Technology) about three to four years ago, they were
being marketed for their therapeutic benefits. As the brand became more
popular, the target demographic increased and more advertising stated
that the shoes could reduce cellulite and tone “buns and abs”. This angle
is where most of the new brands are focusing their marketing campaigns
as well. Hopefully more independent studies will be forthcoming so we
have more unbiased evidence on the claims of these companies. Today
MBTs have a much wider range of styles compared to the five to six styles
I fit people with at one time. The newer dual board designs are far less
“clunky” and orthopaedic looking as their soles are 8mm thinner than the
classic models.
One of the most controversial claims made by some of these companies
concerns weight loss. Without working out or dietary changes, muscle
development caused by wearing these shoes alone results in no change
in weight or even a gain in muscle mass with little or no fat reduction. (1)
12
Summer 2010
Application
Different brands have different intended uses and construction. Although
the Skecher Shape Ups feature a rocker sole visibly similar to the MBT, there
are different characteristics worth examining especially when it comes to
informing your patients.
MBT is based on the concept of natural instability, inspired by tribes of Massai
people who walk barefoot. The shoes feature a rigid rocker sole, which at
one time contained a multi-layer sole including a single layer fiberglass
shank, which allowed almost no forefoot flexion. Kneeling in the shoes was
not recommended and could crack the shank and void the warranty. This
was likely an issue they resolved, as there is currently no mention of it in
their site’s FAQ. MBT’s website has information on several clinical studies
to back their more involved therapeutic claims, from case studies involving
neck pain to ACL ruptures. The first question you may ask as a pedorthist is
“How is a stiff rocker platform likened to walking barefoot?” It seems that the
comparison has more to do with adapting to instability than actual dynamic
motion and gait. (2)
Skechers Shape Ups appear at face value to be a knockoff of the MBT,
but they have a different construction. The Skechers have a lower profile
appearance with a less aggressive rocker, and have a cushioned sole
component, which is thick in the back that gets thinner toward the forefoot.
MBTs have a shorter softer heel component similar to a SACH heel and stiffer
sole construction with no forefoot flexpoint. Skecher’s marketing focus is
more fitness oriented, stating that their product burns calories while “toning
legs, buns and abs.”
Some of the designs with rocker soles have been shown to increase blood
flow and range of motion in the knee and hip joints. We are still waiting to see
more long-term results from using these products over time. (3)
Reebok Easytones have two separate “pods”, one under the forefoot and one
under the heel. They liken their product to balance ball technology and are
much different than the rocker soles found on the aforementioned brands.
Also, the imbalance caused by the rocker soles requires a more secure upper,
while Reebok technology appears more stable since they offer it in a flip flop
slip-on sandal. (4)
Fitflops have a low density midfoot with stiffer heel and toe sections of the
sole. This may create more instability during weight bearing and pronation
but does alter the gait in the same manner as the more pronounced rocker
soles of the MBTs or Skechers. (5) Some other brands worth noting and
researching are Trim Treads and Chung Shi shoes.
Naturally, a few obvious examples of patients you know who avoid these
types of footwear will pop up. Someone with recent Achilles damage or strain
wearing a negative rocker heeled shoe can have increased pain. Other things
to avoid would include painful Os trigonum syndrome, advanced diabetes
and peripheral neuropathy, and very weak and easily sprained ankles. (1)
Although they not seem suited for cases of imbalance or vestibular issues,
some have seen positive results in limited balance training through their use.
There are likely many cases where you could see potential patient success if
these shoes were used in conjunction with other therapies. If your patient
already has a pair, ask them to bring them by during their next appointment
so you can have a look. If you’re really ambitious, try a pair or two on when
you’re out shopping to gain first hand experience on how they feel and work.
Naturally when you market a product as a fitness enhancement, there is
the risk of overuse injury. One of the fitness trainers I used to work with
thought he could train while wearing MBTs for the first time during an
entire 8 hour shift. He could barely walk the next day. A good comparison
would be first time orthotic wearers. We may encourage them to undergo
a “break in” process. Regardless, some patients will not always follow that
advice thinking that more is better or that they may see quicker results.
Moderation is encouraged when wearing this footwear, but when they are
touted as “miracle” shoes, people will have the tendency to overdo it.
It is our responsibility at the end of the day to become informed and keep
up to date with current footwear trends and technology. If we don’t know
what our patients are putting their orthotics into, how can we really know
if the CFOs are doing their job? We can only impress and further assist our
clients by learning more about what they’re putting on their feet.
them in the MBT if they want. People are advised that the MBT probably
will make (in the long run) orthotics unnecessary.”
Statements like that can only inspire more debate and discourse, which will
create a demand for more accountability as well as further research on the
issue. If you claim that you can eliminate the need for an already prescribed
therapy; you have to have the evidence to back it up.
Insurance issues will pop up as more people view these shoes as
orthopaedic appliances. If they are recognized as fitting into the athletic
footwear category, then insurability may be a more clear cut issue as many
plans do not cover athletic shoes. Insurance companies will need more
evidence based on clinical studies if the therapeutic benefits make them
viable as orthopaedic footwear.
Are these shoes safe to wear with orthotics? This is a question open for
debate, and obviously depends on the individual patient and their needs.
When I first worked with the MBTs I noticed that people came in looking
for them after researching them online; so the average consumer can often
be well informed and eager to learn more. As a certified pedorthist working
with your patient, it is up to you to recommend whether your patient can
use these as a fitness enhancement or form of treatment, or if they should
just avoid them altogether.
From the MBT website FAQ:
References
CFO integration and therapy
“Wearing orthopaedic sole inserts in MBTs is not recommended as
orthopaedic inserts support feet, whereby the foot muscles are not
activated as much. MBTs on the other hand, stimulate and activate the
foot muscles. People should try to wear MBT without orthopaedic to fully
benefit from the MBT technology. Initially people with orthotics can use
1 - http://nummyz.wordpress.com/
2 - http://us.mbt.com/Home/Benefits.aspx
3 - http://www.skechers.com/info/shape_ups?cm_re=HP-_-MG-_-Info
4 - http://www.reebok.com/CA/#/womens?view=easyTone
5 - http://www.fitflop.com/benefits/technology/
13
Quarterly
Pedorthics
A Runner’s Footwear Wear Pattern:
Observation and Interpretation
Footwear wear and tear is guaranteed to
happen among runners. At 180-190 strides
per minute, a runner’s footwear is considered their most important
piece of equipment. In order for the body to perform at its maximum
potential, this equipment must be functioning properly as well. The
relationship between footwear wear patterns, gait cycle, lower limb
mechanics, and foot pathologies must not be overlooked. Canadian
Certified Pedorthists are footwear specialists who consider footwear
observation and interpretation an essential part of a complete
pedorthic assessment. A pedorthist is able to distinguish between
uneven and even wear pattern of a worn running shoe.
Normal running shoe wear suggests that a patient has been properly
fitted for footwear. The upper of a worn running shoe should be
comparable to its original shape. Natural wear across the upper
between the first and fifth metatarsal-phalangeal (MTP) joints is
indicated by a gentle crease. An evenly worn inside lining will be free
of fraying and pressure points. A well-fitting shoe does not bulge,
overhang, twist or cause injury. In fact, a healthy fitting shoe is an
important part of effective patient treatment and injury prevention
(Deschamps, 2010, p.2). When wearing the proper shoe, a normal
running gait will begin with the subtalar joint (STJ) in approximately
five degrees of inversion at heel strike during contact period. Prior to
heel strike the tibialis anterior works to stop the foot from slapping
forward while slightly inverting the foot making the runner contact
the ground on the lateral heel. At midstance the runner will be in
approximately 10 degrees of eversion and then resupinate towards
neutral for a stable toe off (Prentice, 2006, p. 533). This is reflected
in normal tread wear, as mild and even wear at the posterior-lateral
aspect of the heel works across to the medial central forefoot
region curving slightly to the first metatarsal-phalangeal (MTP) joint
(Deschamps, 2010, p.2).
Ill-fitting footwear and improper lower limb biomechanics can veer
a runner’s wear pattern away from normal. Irregular wear patterns
cause shoe deformities, produce an off balanced gait, and can trigger
injuries. Comparing a visual analysis of the inside of the shoe, the
upper, and the outsole to a normal wear pattern can help a pedorthist
validate a diagnosis, discover a deformity, or comprehend a patient’s
foot mechanics.
Normal wear on the forefoot outsole should be smooth across the
medial central tread. The wear should bow somewhat to the first MTP
joint for toe off. When excessive wear is concentrated at the center of
the forefoot, it suggests a low transverse arch causing extra pressure
beneath the metatarsal heads upon weight bearing. Such pressure can
be the source of metatarsalgia or synovitis. The transverse arch can be
supported with the use of a metatarsal pad to aid in the alleviation
of uneven plantar pressure and the formation of a more normalized
tread. If unusual wear is noted at the medial forefoot below the first
MTP joint, it implies pronation is present throughout late mid-stance
to toe off. Increased pressure at the first MTP joint could contribute
By Valerie Simpson
14
Summer 2010
to the development of a bunion, hallux valgus or sesamoiditis.
Medial longitudinal arch (MLA) support is recommended as well as
a metatarsal pad. If the wear continues along the medial border or
medial rearfoot of the outsole, it is possible that rearfoot pronation,
or a valgus heel, is present. A medial rearfoot wedge and a deep heel
cup can correct this wear from becoming excessive (Rossi, 1984,
p. 131, and Deschamps, 2010, p.5). With runners who supinate, a
pedorthist will note abnormal wear at the lateral rearfoot and along
the lateral border of the running shoe tread. This can also be caused
by an extreme pes cavus or uncompensated heel varus. Wear can be
evened out before injury occurs through a lateral post or supportive
heel cup (Prentice, 2006, p. 533).
While examining the tread, a pedorthist can look to the upper to
detect whether or not it overlaps the edge of the sole. If the upper is
impending over the sole this indicates that the running shoe has been
fit too narrow or shallow for proper soft tissue expansion upon weight
bearing or the width of the tread is insufficient for the shoe (Rossi,
1984, p.130). The running shoe may be the wrong last shape for the
foot. Running shoes can taper off in the toe box, not offering enough
forefoot room for a rectus foot type. The medial distortion and the
projection of the midfoot may be caused by medial longitudinal arch
collapse and STJ pronation upon weight bearing during mid stance.
Pronation or forefoot abduction can also cause lateral extension of the
forefoot over the sole, proposing a tread that is too slim compared to
the upper. An improper last or narrow fit can also cause bulging of the
upper vamp at the site of the MTP joint, suggesting the formation of
a bunion, or claw and hammer toes. These deformities can be painful
and need sufficient room within the toe box to prevent irritation. A
pedorthist may recommend that the patient invest in a wider shoe to
accommodate for the overhang (Deschamps, 2010, p.2,3).
Distortion and bulging of the forefoot over the edge of the outsole
can cause eversion and twisting of the toe box and vamp. The upper
flexpoint crease should wear a straight line from the first metatarsalphalangeal joint to the fifth. If a running shoe is improperly fit, the
crease may run oblique or be absent. An excessively oblique crease
will indicate failure for the first MTP joints to dorsiflex, signifying a
hallux rigidus is present. An absent line would suggest a short stride
and flat footed gait with very limited propulsion. A rocker sole would
benefit the patient to encourage straight forefoot flex (Carter, 2009).
If the vamp crease is deep and excessive on the running shoe it is
possible that there is too much space in the shoe. A narrower or
shorter fit would be appropriate (Deschamps, 2010, p.3).
A running shoe that is too narrow, too short, or the wrong last shape,
can also source wear to develop on the inside roof of the toe box
leading to blistering and callusing of the phalanges (Rossi, 1984, p.
43). A small shoe can produce excessive wear on the inner heel of
a running shoe. This type of wear may also indicate an inverted or
everted subtalar joint or a haglunds deformity. A wedge can be placed
inside the rearfoot to correct the excessive inversion or eversion
and wear (Deschamps, 2010, p 4). A pedorthist must remember to
observe the worn sock liner of the running shoe. The areas that are
visibly darker indicate where much of the patient’s pressure is while
weight bearing. Wear is common under the calcaneus and metatarsal
heads. Some wear should be obvious along the outer shank region.
If no wear is present in this area it implies that the lateral arch is not
weight bearing, therefore adding extra pressure to the metatarsal
heads and calcaneus (Rossi, 1984, p. 92).
Throughout the entire footwear wear analysis, the pedorthist will
be noting differences between the left and right running shoe. Such
differences could indicate that a leg length discrepancy may be present.
A leg length discrepancy can be noted through the “wind swept” look
of a pair of shoes. One shoe will demonstrate lateral rearfoot distortion
and the other will have medial rearfoot deformation. The lower limbs
must be measured and possibly be treated with an intrinsic or extrinsic
lift (Deschamps, 2010, p. 6). If the legs were measured equal the
differences could also impose that the patient is constantly running
on one side of the road. Most streets or side walks are slanted towards
the drains and ditches, therefore the outside shoe will have more wear
on the outsole as it is always traveling an additional distance before
contacting the inclined pavement or gravel.
A footwear analysis is intended to find problems in the shoe fit and
may assist to diagnose foot problems. A pedorthist can recognize
the sources of potential problems through footwear wear evaluation
and use this knowledge towards effective patient treatment. This
examination does not require any extensive length of time as a skilled
and practiced pedorthist can gather the information in a matter of
minutes (Rossi, 1984, p. 131). A patient’s current worn footwear is a
very valuable evaluation tool during an assessment. The shoe upper
and tread wear patterns can suggest interesting discoveries for a
patient’s condition and treatment.
References
Carter, P. & Bird, A. R., Course Notes: A Problem Solving Approach to
Footwear Fitting, La Trobe University, 2009.
Deschamps, L., PEDS 6013 Course Notes: Week 9, Shoe Wear Analysis,
University of Western Ontario, 2010.
Prentice, W.E., Arnheim’s Principles of Athletic Training: A CompetencyBased Approach, 12th ed., The McGraw-Hill Companies: New York,
New York, 2006.
Rossi, W. A. & Tennant, R., Professional Shoe Fitting, Pedorthic
Footwear Assoc. Washington, DC, 1984.
Well established, full service pedorthic
facility seeks
C. Ped (C), C. Ped Tech (C), or Kinesiologist.
Compensation package includes competitive salary, medical
benefits, membership dues, educational opportunities.
Please direct resume to Paul Lucas, plucas@bioped.com.
15
Quarterly
Pedorthics
Summer 2010
Their results were impressive, but not in a way that favours the
widespread use of running shoes. When the group ran in the shoe they
produced 38 per cent greater knee varus torque per stride than when
running barefoot. Furthermore, running shod resulted in a 36 per cent
increase in knee flexion torque and a 54 per cent increase in hip internal
rotation torque (amount of force leveraging the knee into flexion and
the hip into internal rotation, respectively). It was speculated that
these outcomes were a result of the effective 12mm heel lift present
in the Brooks Adrenaline shoe, contributing to an exaggerated loading
response from the hip down.
Looking at the ground reaction forces themselves, according to Kerrigan
et al. running shod resulted in significantly less propulsive force and
significantly greater overall ground, as well as medial/lateral, reaction
forces. These outcomes likely have to do with the softness of modern
running shoe mid-soles that dampen the initial impact of the heel, but
also weaken the foot’s leverage against the ground for push-off on a less
stable platform requiring greater overall force applied to the ground in
order to run at the same speed.
The implications from these findings are huge. Running shoes now
have the potential to contribute to the following: osteoarthritis of the
knee (through the knee varus torque), patellofemoral pain syndrome
(through greater knee flexion torque), iliotibial band injury (through a
modest but significant five per cent greater hip adduction torque) and
a reduction in running performance (through the combined effect of
decreased propulsive force and increased medial/lateral reaction force).
Despite the potential consequences from the outcomes of Kerrigan’s
work it needs to be considered that this study is approximating the
forces surrounding the joints; these results are not reflecting actual
joint contact forces. Moreover, the design of the study can at best
speculate on the consequences of these higher torque values. A more
robust prospective randomised clinical trial is needed to provide further
evidence of any specific detrimental effects of running shoe wear.
Nevertheless, it is hoped that Kerrigan’s study conjures up discussion
and perhaps a renewed critique of our current footwear prescription
paradigms. Running shoes may or may not lead to knee OA, but we
should now question whether they are optimally designed to prevent
injuries or simply to feel comfortable out of the box.
Since When Did Running in
Shoes Lead to Knee OA?
Article Review: The Effect of Running Shoes of Lower
Extremity Joint Torques. Authors: Kerrigan DC, Franz JR,
Keenan GS, Dicharry J, Croce UD, Wilder RP PM&R 2009;
1(12):1058-63
There is a commonly held belief that
By Michael Ryan,
PhD, C Ped (C)
running shoes represent the pinnacle in
the advancement of footwear support.
No other footwear category incorporates as many technological advances
(from stabilizing mid-foot shanks to modified midsole densities to
impact attenuating systems at the rear-foot to ultra-breathable uppers)
in the interest of appealing to a market of increasingly savvy athletes
and health care professionals. Indeed, running shoes are arguably the
most laboratory tested shoe in the world in the interests of validating
so many marvels of stabilization and comfort. Yet there remains limited
to no evidence that any of these footwear advances achieve one of their
intended goals: to prevent running injuries.
Kerrigan’s paper in the peer-reviewed journal PM & R (Physical
Medicine and Rehabilitation) offers some insights on why this may
be the case, with thought provoking conclusions that could change
how and when we decide to prescribe running shoes. The authors
performed three-dimensional motion analysis of the lower extremity
on an instrumented treadmill to measure ground reaction forces on 68
young healthy male and female runners. The central question in this
study was to compare how ground reaction forces were distributed on
lower extremity joints (particularly the knee and hip) when runners
ran in a conventional supportive running shoe (Brooks Adrenaline)
versus when they ran barefoot at a controlled speed. Kerrigan’s chief
outcome measure in this study was the external knee varus torque – or
the amount of ground reaction force that is leveraging the knee into
a varus position (i.e. knee adduction). High amounts of a knee varus
torque can disproportionately increase the loading on the medial
compartment of the knee during running, a concern by many that
contributes to premature osteoarthritis.
Author’s Note: A copy of Kerrigan et al’s (2009) study has been made available upon request.
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OPREG UPDATE
By Matt Quattrociocchi,
Summer has seen babies and
vacations pile up for the OPREG
crew and we are starting to get
ourselves ready for a busy fall schedule. Our main focus will be to
follow up from meetings and communications with three specific
groups; the College of Chiropodists of Ontario, the regulation arm of
the Ontario Association for Prosthetics and Orthotics, and the College
of Kinesiologists of Ontario. We are in pursuit of establishing a suitable
and willing partner to begin discussion of a joint college venture. This is
a slow process but a very exciting time for pedorthics and we will keep
you updated on our progress.
We thought it might be good to refresh everyone on the merits of
legislative regulation and why OPREG continues to work on behalf of
the Ontario pedorthists.
What is health profession regulation
and why is it important for pedorthists?
Regulation: “governance or control by act of law”
In Ontario, 21 health regulatory colleges govern the practice of
more than 256,000 health care professionals, including physicians
and surgeons, dentists, nurses, technologists and most allied health
professions. Chiropody and podiatry footcare providers are regulated
health professions. While Pedorthics has a voluntary national college to
regulate practice, it is not regulated provincially– yet!
The colleges that regulate health professions:
•Set and enforce standards and guidelines for
practice and conduct;
•Ensure practitioners meet entry to practice standards
and control use of title;
•Develop continuing education and quality
improvement programs; and
•Respond to public concerns about health care.
Becoming a regulated health profession ultimately protects the public
and increases accountability at the provincial level. It also increases the
profession’s visibility and credibility with the public and other health
professions and allows the profession to protect the use of the term
“pedorthist”.
What is the process for achieving regulation?
Health care regulation is determined by the Ontario Ministry of Health
and Long Term Care (MOHLTC), which takes advice from the Health
Professions’ Regulatory Advisory Council (HPRAC). www.hprac.org
Why now?
A window of opportunity is available. governments have been unwilling
to expand the number of regulated health professions, the Ontario
Liberal government has recently approved regulation for kinesiologists
and several other professions and has asked HPRAC to review the
footcare model in Ontario.
Do PAC and the college support pursuing regulation?
The College of Pedorthics of Canada (CPC) supports the OPREG initiative
as we endeavor to seek provincial regulation in Ontario. Provincial
regulation is an undertaking of both time and money. CPC supports our
effort and believes that the public and CPC will benefit nationally from
the experience we gain in seeking government regulation. The CPC was
created and modeled after provincially regulated professions and they
have shared the information they have gained as an organization with
OPREG in our efforts. The CPC supports OPREG while maintaining the
national perspective.
The Pedorthic Association of Canada (PAC) supports the pursuit of
government regulation of pedorthics as a means to greater recognition
and respect for the profession within the general public, the medical
community, and the insurance industry.
As regulation of healthcare professions is a provincial matter it is difficult
for PAC to assume this task nationwide. As such, PAC commends and
endorses the work the members of OPREG have undertaken towards
this goal and thanks those PAC members who have contributed
financially to aid OPREG in our pursuit.
PAC makes a financial contribution to OPREG as the Board of Directors
believes that the work done by OPREG to date and planned for the
future is beneficial for the entire profession. PAC makes this investment
in OPREG on behalf of members nationwide, with confidence that
should other provinces wish to pursue regulation the knowledge and
experience gained by OPREG will prove invaluable.
To provide input or discuss OPREG’s progress, please contact us by
visiting our website, www.opreg.ca.
Our thanks to many Ontario members (and even some from outside
of Ontario) for your financial support. We continue to work on your
behalf. Anyone who has not already contributed for 2009, please do
so. Thank you.
Interested in
career opportunities
in your area?
Visit www.pedorthic.ca for listings.
For information on placing an ad,
email: info@pedorthic.ca
17
Quarterly
Pedorthics
Summer 2010
Promote your practice with PAC-produced brochures
Why Choose a Pedorthist?
What is a Foot Orthotic?
This brochure explains the role of a
C. Ped (C), the services they provide,
what problems they can help with and
how they differ from other foot health
professionals.
This brochure covers the basics of a
foot orthotic including who needs one,
what they look like, how long they last,
and why it’s important to wear orthotics
with proper footwear.
Many other brochures are also available.
For a full list, or to order brochures or other PAC Promotional Products, please visit
the member’s side of the PAC’s website, www.pedorthic.ca.
All brochures are $25.00 plus applicable taxes per 100. All brochures can be personalized.
Please contact the PAC office at info@pedorthic.ca or call 1-888-268-4404 for more information.
Clinical Positions Available
OKAPED
Clinical
Positions Available
is currently seeking a full time C Ped (C) at our new
Salmon Arm
office and
our well
established
Vernon
of 13 yrs.
OKAPED
is currently
seeking
a full
time C Ped
(C) atoffice
our new
Salmon Arm office and our well established Vernon office of 13 yrs.
Applicant
Applicant requirement
requirement
• Attained a University degree in Kinesiology or related field
- Attained a University degree in Kinesiology or related field
• Have your C Ped (C) certification and be in good standing with the CPC
- Have your C Ped (C) certification and be in good standing with the CPC
We Offer Clinicians
We Offer
Clinicians
Professional
level salaries - Continued education expenses - PAC and CPC fee coverage
PAC Symposium fee and travel - Professional Insurance fee coverage - Extended Health
90 minlevel
assessment
with- HD
video of alleducation
clients - Use
of CBAS online
assessment
Professional
salaries
Continued
expenses
- PAC
and CPCsystem
fee coverage
90% Clinical duties, 10% lab duties - Orthotic fabrication for your clients in 5 days
PAC Symposium
fee and travel - Professional Insurance fee coverage - Extended Health
Moving expenses to assist you relocating - Working with a Team that loves their work
90 min assessment with HD video of all clients - Use of CBAS online assessment system
If you are ready for a change or are just starting out consider these opportunities. Have a look at:
90% Clinical
duties, 10%
lab more
duties
- OKAPED
Orthoticorfabrication
for your clients in 5 days
www.okaped.com
to learn
about
call Jeff at 250-868-8665
send your
resume
andrelocating
any questions
have regarding
this opportunity
to Jeff@okaped.com.
MovingPlease
expenses
to assist
you
- you
Working
with a Team
that loves
their work
18 If you are ready for a change or are just starting out consider these opportunities. Have a look at
Shoe Anatomy
By Jim Pattison,
C. Ped (C)
1. Buttress – A broadening of the sole that extends onto the upper
for increased stability.
4
2. Flare – A broadening of the sole that does not extend to the upper.
It is for increased stability.
3
3. Last – The form on which the shoe is built. This customized last is
built to the shape of the foot.
4. Heel Counter – This is the piece that fits in at the heel. It provides
shape to the shoe at the heel and it provides a source of stability and
motion control as well.
5
5. Toebox – This is the material that will form the toebox of the shoe.
It is a material called Celastic and it is activated by solvent and heat.
The purpose of the toebox is to provide shape and aesthetics at the
toe and to prevent the upper from coming down on the toes.
6
7
6. Vamp – The vamp is part of the upper which can cover the top part
of the foot. This is the vamp of a cowboy boot at the right-hand side.
7. Toe – The toe of this boot with the toe cap is to the left of this
picture.
8
8. Insole – This is the piece that the upper is attached to. In this case,
it is from the cowboy boot shown above.
9. Heel seat – This is the piece of leather that covers the insole and
the nails that are in it.
9
10. Heel block – This is the part of the shoe that sits between the
heel lift and the sole. In this case, it is for a cowboy boot and the block
is tapered distally. Some other heel blocks are flatter. This one has a
noticeable indentation for the heel to sit in.
10
11. Heel block – In the case of a dress shoe, the heel block is more
flat and is not tapered distally.
12. Heel lift – This is what most people would call the heel. It is the
rubber part that is attached to the heel block.
13. Heel – A unit made up of both the heel block and the heel lift.
14. High Heel – This is a heel that would go on a lady’s shoe. The
heel lift is a rubber tip that goes on the end of this heel. Since it has
a pin that extends into the distal end of the heel, that style is called a
pin lift.
11
14
19
www.pedorthiccongress.org
PEDO R T H I C S & the
2010 North American Pedorthic Congress
Thursday, November 18 to Sunday, November 21, 2010
H ilton Walt Disney Wor ld R esor t, Or lando, Flor ida

Pedorthics - Pedorthic Association of Canada

Transcription

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