| Lisa Knox

Foot Notes: August 28th, 2019

From the desk of Kevin B. Rosenbloom 
Here's a dose of what I'm pondering and enjoying this week ...

Ted Talk: Ancient Rome's Most Notorious Doctor
A 5 minute documentary on how Galen of Pergamon, a Roman doctor, influenced anatomists and doctors for centuries and how Andreas Vesalius challenged his ideas. Complacency is too comforting and time-consuming but challenging ideas is essential. This is a great example of why experts of various fields should spend the time to read and ask questions. As a result, education in any topic can grow in a better direction. Watch here

Osteoarthritis: a consequence of evolution?
by T. Hogervorst
Dr. Hogervorst briefly dives into fetal hyperflexion of the femur at the pelvis during pregnancy is a potential result of evolution. The description of this process can be directly related to osteoarthritis seen in the pelvic region. Definitely worth a read if you enjoy hominid evolution and modern pathology. Read here 
Katy Bowman's Move Your DNA Podcast: Taking Bone Mechanics by the Horns
This podcast is a little long, but essential. Bowman and Loram discuss the differences between newspaper articles and research studies while dissecting the latest "horns" growing on the posterior base of the skull. They also clarify some misconceptions regarding the terms and methods of evolution and adaptation. Note that Bowman is great with biomechanics but not necessarily an expert with the foot. Listen here

Custom orthotics and hammertoes: Response from Dr. Keith Gurnick
From Kevin:
So it goes, I was shown up by the venerable Dr. Keith Gurnick of Beverly Hills during a conversation on hammertoes. He was just not satisfied with my response to treating hammertoes, and frankly, I have to concede. His response is fantastic. Check it out - now you will be an expert for treating hammertoes. And if you don't have a Sani-grinder in your office - time to pony up and get one. AliMed has Sani-grinders to purchase here. Enjoy!
From Dr. Keith Gurnick:
Custom Prescription Foot Orthotics can play an important role in the care and long term management of some patients with a primary complaint of hammertoe deformity, who also exhibit over-pronation of the feet. Orthotic prescribing considerations must include the types of shoes in which the orthotics will be worn. Rigid, non-reducible and long-standing hammertoe deformity would not be expected to show positional improvement, however, pain symptoms and or the formation of corns, calluses or skin ulcerations can improve but may not completely resolve. The use of any custom foot orthotic, when prescribed for hammertoe deformity will often require either shoe selection changes to either deeper or wider toe box, softer upper materials, and in general more volume because the orthotic will take up room in the shoes. Although 3/4 length orthotics (a shell with an extension and top cover and STS padding) are less bulky in the toe box than full-length orthotics, I have found that most patients do not like the feel of the drop off at the end of the 3/4 length extension and prefer or have more comfort with full-length extensions. If a 3/4 length extension is ordered, it should be adequately tapered to paper-thin at the end of the extension which should be just proximal to the sulcus of the toes and the proper metatarsal parabola for each patient's individual feet. A prescriber who dispenses should have scissors and a grinder available in the office to do on the spot fine-tuning and adjustments when needed. With regards to the specific prescription, the cast balancing techniques should take into account specific issues such as forefoot varus or valgus and posting to treat the rear foot. On some patients, properly placed metatarsal padding of specific thicknesses can be helpful with hammertoes, but flexible reducible hammertoes do better than rigid hammertoes. When treating patients with hammertoe deformity and pronated feet with foot orthotics, a bulky orthotic that crowds the toes is doomed to failure. The patient needs to understand what the goal of the orthotic treatment is, and must be compliant with shoes to work towards achieving the goal. If the orthotic is too bulky for the shoes, you will fail to help the patient. Always try to prescribe the least bulky orthotic that you feel will get the job done.

Hope this helps. 


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