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In June, our guest expert in Le Club's Ask the Expert segment was Julie Giroux, BSc(OT), OTReg(Ont), CPed(C), a Canadian Certified Pedorthist and Registered Occupational Therapist at the Foot Care Centre at Women's College Hospital.

Julie provides biomechanical foot assessments, education and advice on proper footwear and off-the-shelf foot-related products, and custom-made orthotics.

Since 1985, the Foot Care Centre at Women's College Hospital has provided specialty foot care services to individuals in Toronto. The Centre employs a multidisciplinary team of occupational therapists, chiropodists, orthotists, and pedorthists, to provide the best care for your feet.

Some common reasons people visit the clinic are concerns about hammer toes, bunions, heel pain, arch pain, excessive pronation or supination of the foot, and foot problems caused by arthritis and diabetes.

Here are Julie's answers to your questions about Foot Care:

Q: I have noticed that over the last few years, the 'big toe' joint on my right foot has enlarged (a bunion, I think. I can still wear normal shoes, but find this asymmetrical widening concerning. I attribute this partially to bad shoes, but also to genetics (all women on my mom's side have wide feet). Just curious if there is anything I can do to reverse this widening, or at least stop it from progressing. Thanks!

A: Many people have problems with the 'big toe' joint (also known as the 'first metatarsophalangeal' joint) so you are not alone! There are a variety of problems that can affect this joint which can cause a bony prominence commonly called a 'bunion'.

There are different things you can do which may reduce the progression depending on the cause, but there is generally nothing you can do to reverse it (except in some cases where surgery is indicated).

Your first step should be to see your doctor or a foot health professional such as a pedorthist, chiropodist or podiatrist to determine the source of your problem and for advice specific to your feet! One piece of advice I can give is to never try to squeeze your feet into shoes that are too narrow - it will only make the problem worse!


Q: I always have a corn between my little toes. I put a pad there to help me to prevent the hurt. What can I do other than use a medication pad? I am a diabetic but my doctor told me it is OK.

A: While I can't give you advice specific to your situation, I want to emphasize that people with diabetes need to take extra care not to injure their feet. Due to the disease process of diabetes your feet can develop complications such as loss of sensation and skin ulceration which can be quite serious.

Your mention of 'medicated pads' concerns me as they usually contain a substance that burns the corn and could injure your skin. On the other hand, a cushion or gel pad can help reduce pressure and pain from a corn.

I would advise you to consult with your doctor to clarify exactly which products are appropriate for you and perhaps request a referral to a foot care nurse, chiropodist or podiatrist who specializes in foot care for people with diabetes to treat the corn directly.


Q: I have a recurring problem. At the point where the achilles tendon comes down into the heel it is always tender and slightly swollen. What can I do to alleviate the problem? What causes it? Is physiotherapy my only recourse?

A: The area where the Achilles tendon attaches to the heel contains several structures that could be the source of your problem. There are two bursa located near the Achilles tendon insertion, as well as the Achilles tendon itself which could be inflamed. Some people also have a bony prominence near the Achilles tendon insertion on the heel.

You need to find out exactly which structures are affected. There are a number of causes for irritation to this area including structural weakness of the tendon, sports injury, overuse, and inappropriate/tight footwear to name just a few.

You should consult with your doctor as well as a pedorthist to determine the source of your problem and specific treatment which may include medication, orthotics and special features to look for in your shoes.


Q: What is the best way to deal with hard skin on the feet? What about hammer toes? I am 75 years old. Thank you.

A: Hard skin such as calluses and corns on the feet is often caused by excessive pressure or rubbing on the skin from footwear or inadequate fat padding on the soles of the feet especially as people age.

Hammertoe deformity is a common deformity often affecting the second toe which causes it to remain flexed at the middle joint of the toe. Technically what occurs is a flexion deformity of the proximal interphalangeal (PIP) joint of the toe with hyperextension of the metatarsophalangeal (MTP) and distal interphalangeal (DIP) joints. This can cause the middle joint of the toe to press up into the upper of your shoe causing a hard corn to develop.

As you might have already guessed, relieving pressure is one way to deal with hard skin on the feet. I would first recommend that you consult with your doctor and a qualified foot health professional to help you determine why you have hard skin on your feet and for specific advice on your situation.


Q: Is it true that the soles of the feet become thinner with age? I am 57 years of age and having been walking for exercise for many years. However, starting about three years ago, I began to have pain in the forefoot.

For the past two years, I have worn a custom-made hard plastic orthotic in my athletic shoes with great success, but recently, the pain in my forefoot has gradually returned, even though I have reduced the mileage I walk from four miles to two miles at a time.

My podiatrist checked my athletic shoes and my orthotics, which were fine. He adjusted the orthotics by removing the leather cover and padding, but this made the pain much worse. After letting my feet heal completely, I finally took out the orthotics and tried walking without them, wearing just an over-the-counter cushioned insole, and the pain improved almost immediately.

I no longer wear the orthotics, and the podiatrist suggested that I simply no longer need them. However, I do not understand how this is possible. Is this a common occurrence with orthotics? And if so, what is the reason? Thanks for your help.

A: I have heard variations of these question many times in my practice. I will answer your questions by providing more information about age-related foot changes and orthotics.

Thinning of the fat pad on the soles of the feet and thinning of the skin can be age-related especially when diseases are present such as diabetes or arthritis which become more likely as people age. If the toes are 'clawing' (ie. curling) the fat pad under the metatarsal heads (the area people call the 'ball of the foot') can shift forward toward the toes, leaving the metatarsal heads more prominent which can cause forefoot pain. However there are many different causes of forefoot pain and you need to have your feet examined by a professional to determine the source of your pain.

Under normal everyday use 'rigid' plastic orthotics will generally last between 2 to 4 years depending on the rigidity of the devices, the activities you are using them for (eg. running or walking) and how often you wear them. Obviously the softer, 'cushioning' components may wear out in much less time and need to be replaced to maintain their effectiveness.

In some cases people require orthotics for a specific acute injury and can stop using them when the injury has healed. However, most people who require orthotics, especially those with low medial arches or 'flat feet', need to continue wearing orthotics and appropriate supportive footwear on an ongoing basis to maintain adequate symptom relief.

Some of my patients report that they can 'go without' their orthotics for a few days or even a few weeks with appropriate footwear but many tell me that their symptoms gradually return. Others tell me they 'can't live without' their orthotics.

Orthotic devices can be made from a variety of different materials based on your foot structure, activities and footwear that the devices will be used for, and the specific problem they are intended to treat. All of these factors play a role in how orthotics function and their longevity. Your orthotic provider should be able to answer your questions specific to your unique condition and orthotic requirements.

I hope that helps!


Q: What could be the cause of a rather painful burning sensation at the "ball" of the feet (near the toes)? What can be done about it?

A: There are a number of conditions that can cause the symptoms you describe. You should see your doctor for an initial diagnosis of the cause and any special tests you may require. Depending on the diagnosis, it may be recommended that you see a pedorthist for footwear advice and possibly orthotics to help alleviate this problem.


Q: A part of my instep on one foot is always itchy. It doesn't show any rash, or bumps but is always itchy. Athlete's foot lotion has not helped. I wear sneakers and socks everyday, and keep them very clean. Do you have any idea what might be causing this itch?

A: I would recommend you see your doctor for a diagnosis of this problem. Even if the problem is 'Athlete's foot' you may require a different medication. Good luck!


Q: I can't wear shoes that are narrow because my baby toe nail hurts when the shoe is pressing against it. It's been like that for a few months and I'm a person who usually wears flat shoes or runners all the time. Both of my baby toes nails have a split in the middle of the nail but it is only one foot that bothers me.

A: Wearing shoes that are too narrow can cause pain in the toes and could be the cause of the problems with your nail. You should have your nails examined by your doctor to determine the cause of the splitting which could be due to pressure from shoes that are too tight but could also be caused by some other disease process that you doctor could diagnose. Regardless, you should be careful not to wear shoes that are so tight that they cause pain!


Q: I have fungus on my toes and recently started taking Lamisil 250mg OD. I have yet to see a change. Do I have to remove the infected toe nail?

A: As a pedorthist, I am not involved in prescribing medication. I would recommend that you discuss your course of treatment with your doctor and/or pharmacist. They can advise you as to how long it could take to see results with Lamisil. Keep in mind that nails take a long time to grow and the infected portion can take months to grow out completely!


Q: What is the best solution for ingrown toenails? My son, age 45, had the nails of his big toes removed unsuccessfully. The second time they were removed they were treated with acid. Is that what you recommend? Who does it and how?

A: As a pedorthist I am not involved in treating ingrown toenails directly. I would recommend that you consult with your doctor, or a chiropodist or podiatrist who could advise you of the best treatment options. One pedorthic consideration for ingrown toenails is footwear. Sometimes wearing a shoe that is too narrow or tapered at the toe can encourage an ingrown toenail. Certainly if you already have an ingrown toenail it may be more comfortable to wear an open-toed shoe or sandal to relieve pressure.


Q: I am a 54 year old professional skating coach with sore feet but otherwise in good health. My feet are swollen just back of my toes with more involvement on the right foot than the left. Upon rising in the morning they are tender when weight bearing. I think I should consult a podiatrist on this issue but thought I would start with your Ask the
Expert forum first.

A: This is a difficult question to answer in this forum. I would definitely suggest an assessment by your doctor who could order any diagnostic tests that may be required (such as an X-ray).

Your symptoms may be something minor that could be easily remedied or may require more specific attention. It sounds like you are having pain and swelling in the area of the metatarsal heads which contains a number of anatomical structures which could be affected including the metatarsal bones, nerves and tendons that pass through to your toes.
Once you see your doctor, a foot health professional such as a pedorthist could provide you with treatment options which could include shoes to address your specific problem or a type of off-the-shelf shoe insert or custom-made orthotic devices.


Q: I noticed that you are a 'Pedorthist' - what is that?

A: A pedorthist is a health professional who is trained in the assessment, design, manufacture, fit and modification of foot appliances and footwear for the purposes of alleviating painful or debilitating conditions and providing assistance for abnormalities or limited actions of the lower limb.

A pedorthist may provide orthotic devices and footwear to assist in:

- Accommodation of foot deformities;
- Re-alignment of anatomical structures;
- Redistribution of external and internal forces;
- Improvement of balance;
- Control of biomechanical function;
- Accommodation of circulatory special requirements; and,
- Enhancement of the actions of limbs compromised as a result of accident, congenital deformity, neural condition, or disease.

There are three different designations of Pedorthist in Canada with different levels of qualifications based on the scope of practice they provide. The most common type of Pedorthist you would encounter to obtain custom-made orthotics is a "C Ped (C) - Certified Pedorthist (Canada).

These clinicians may also have degrees in other health professions including Occupational Therapy or Phyiotherapy. All Pedorthists must meet the criteria set out by the College of Pedorthics of Canada and pass their certification exams.

For more information on Pedorthics go to: www.pedorthic.ca.


The following are commonly asked questions about foot orthotics:

What is the purpose of foot orthotics?

Orthotics are used to promote normal foot function while preventing irregular weight bearing and abnormal stress to the structures of the foot and lower extremity. Depending on your foot structure and the type of problems you are having, your orthotics may be made of soft flexible
material or hard rigid material.

How are orthotics made?

Custom-made orthotics are made from a three-dimensional impression of the feet and fabricated from raw materials. In my practice, I make most of my orthotics from non-weight-bearing plaster casts of the patient's feet. The goal when casting is to capture the shape of the foot with it aligned properly.

How long should my orthotics last?

The longevity of orthotics depends on a number of factors including: rigidity of the device, how often it is worn, and the activities the devices are used for (eg. walking vs. running). A typical rigid or semi-rigid device made from plastic will usually last between 2 to 5 yrs.

Questions to ask of your orthotics provider:

1. What are your qualifications?

2. What casting method do you use?

3. Who makes your orthotics? Is your lab accredited by the "Board for Accreditation of Prescription Foot Orthotic Laboratories"?
4. What do you do if the orthotics don't help?!


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