Murray's Shoes - Since 1875





Foot Problems
 
Foot Problems - The Truth 
Treating the cause not the symptom!

SOLVING FOOT, ankle, knee, hip, and back problems is usually not as simple as putting an arch support into a properly fitted shoe, as many ads claim. Anti-inflammatory drugs, cortisone shots, heel lifts, heel cups, and cushion shoes may treat the symptom temporarily but do not address the cause. There are no miracle shoes.

THE HUMAN BODY is made up of bones, joints, muscles, tendons, and ligaments. The mechanics of the body are all interconnected, functioning at different times in the walk cycle, and having a certain range of motion. Anytime there is a breakdown in the muscular/ skeleton system, the affects can transfer the pain to another part of the body. Understanding the biomechanics of the body and being able to trace the symptom area back to the cause of the pain is the more effective solution of solving the discomfort for the future.

OUR CERTIFIED PEDORTHISTS take their experience and knowledge of lower limb musculoskeletal biomechanics and apply it to either the doctor’s diagnosis or to their own assessment of the patient’s symptoms. Their goal is to balance both sides of the lower extremities, from foot and ankle through knees to hips. As our pedorthist assesses the biomechanics, he gives the physician or the patient many conservative, or non-surgical, treatment options. These can range from shoes professionally fitted, shoe modifications to assist in the control or realignment of the foot deformity, to over-the-counter or custom-made foot orthosis for improved support.

FOOT PROBLEMS

Heel Pain
Metatarsal Pain & Mortons Neuroma
Bunions
The Diabetic Foot
Stretching Exercise

Heel Pain

 Heel pain is one of the most common foot problems encountered by physicians. Once a fairly complex problem to diagnose and treat, studies today indicate that conservative measures should be incorporated as the first line of treatment. The most common type of heel pain is due to a condition called plantar fascitis. The plantar fascia is a fibrous band of tissue that normally extends from the heel to the ball of the foot in a “bow string” fashion. When the plantar fascia becomes over-stretched or strained, excruciating pain is most commonly felt under the heel.

A recent heel pain study, performed by the American Orthopaedic Foot & Ankle Society (AOFAS), clearly demonstrated that for the initial treatment of plantar fascitis, an over-the-counter, custom-fitted, or custom-made foot orthosis (depending on the foot deformity and the degree of severity), a well-structured shoe, and a routine of stretching exercises, is the best way to relieve heel discomfort.

Symptom

When you first get up in the morning, the pain in the bottom of the heel is a dull, intermittent pain or bruise-like feeling which may progress to a sharp, persistent pain. But after walking for a few minutes, the pain slowly disappears. As the day continues and your activity level increases due to sports activity or work related issues, the pain may return. Whenever you sit for a period of time and get up, the pain returns until the foot limbers up. Even when you get out of a car after driving for a time, there will be pain. Although both feet can be affected, it usually occurs in only one foot.

Cause

Heel pain is generally the result of faulty biomechanics (excessive pronation) which places too much stress on the heel bone and the soft tissues that attach to it. The cause of pronation can be due to trauma, genetic formation, ridged big toe joint, ankle fixation, leg difference, surgeries that failed to get the results needed, or, more often, to tight calves.

Tightness of the calves can prevent the foot from going through the normal flexible movements during motion and creates an excessive inward rotation of the foot. This creates an abnormal amount of stretching and pulling on the fascia, which causes tears and inflammation in the soft tissue. Excessive pronation may also contribute to injury to the hip, knee, and lower back.

Treatment

Treatment is not as easy as A-B-C, but it does involve simple steps to relieve the pain and inflammation. But don’t expect a quick cure. It can take up to six months or longer before your heel is back to normal. The goal of treatment is to heal the tears and decrease inflammation, as well as prevent the condition from recurring. Although you may find the slow course of healing frustrating, patience is important. Following are the key elements in relieving heel pain.

REST: Use pain as your guide. If your foot is too painful, rest it.

FOOT ORTHOSIS: An orthosis is designed to support and align the lower extremity, prevent or correct deformities, substitute for function, and relieve pain. Despite the uniqueness of each patient, mechanically speaking, the general goals of orthotic therapy are the same for all. Dysfunctional movement patterns, such as pronation, must be discouraged and muscle weakness must be controlled to provide a stable stance phase during periods of weight transfer. Each orthosis must realign mechanical levers of the forefoot and hind foot in all three planes of motion to provide a stable base of support. While its goal is to improve foot function, which is what every orthosis aims for, a foot orthosis can only achieve its goal in conjunction with a shoe.

SHOES: The success of the foot orthosis to achieve its goal relies on the foundation, called the shoe, that the foot orthosis rests on. To maximize the efficiency of the foot orthosis, the shoe must meet the following requirements:

  1. Proper fit to the foot and its shape with the foot orthosis in the shoe.
  2. As wide of a base or sole as that of the foot orthosis.
  3. Firm heel counter extended as far forwards as possible on both sides.
  4. Firm sole to ensure a natural contact with the ground causes minimal rolling.
  5. Ample room inside of the shoe to allow the foot orthosis to lay flat.
  6. Tie shoe in order to gain as snug a fit as possible over the instep and around the heel.
  7. In some cases extra depth in the toe area.
  8. You should never walk barefoot! Birkenstock, Finn Comfort, or Chaco are recommended for around the house or at times when not in orthotics.
  9. When there is any fixation in either forefoot or hind foot, a rocker sole may have to be added to the shoe(s) to assist in the normal function of the foot.
STRETCHING: Three-quarters of individuals suffering from heel pain can find significant relief with a regular stretching program that includes calves/Achilles tendon and plantar fascia stretching. Adding a foot orthosis and well-structured shoes leads to an even better result. The stretching exercise at the end of this page has been recommended by the American Orthopaedic Foot & Ankle Society.

Metatarsal Pain & Mortons Neuroma

 The foot acts as an interface between the ground and the forces of the body. As it becomes a brake when the heel strikes the ground, it becomes a propeller at toe push-off. In between these two stages, the foot acts as a shock absorber for the body.

As the foot progresses forward down the outside of the foot after heel-strike, the forces move across the foot from the 5th metatarsal joint to the 1st metatarsal joint. Then it moves forward with push-off at the 1st toe.

All five of the metatarsal joints make up one of the shock absorbers. Underneath each of these joints are nerves which feed between the web of each toe to its end. As these bones collapse, discomfort may occur under the ball of the foot or extend out to the toes. These conditions are called Metatarsalgia and Mortons Neuroma. Metatarsalgia is simply an inflammation of the fluid-filled sacs or bursae which are located under each of the lesser metatarsal heads. Morton Neuroma is a benign tumor or enlargement of one of the nerves that travels under and between the metatarsal heads.

Symptom

When you stand and put weight on your feet, you may experience what feels like a bruise on the bottom of your foot behind your toes. As you start walking, this feeling most likely turns to burning, sharp pain, electrical shocks to the toes, or possible numbness to a couple of toes. In addition to this discomfort, you will sometimes feel like your socks are balled-up under your toes. Callouses may also appear across the ball of the foot where metatarsal heads are protruding through the fatty pad.

Cause

There are many reasons for this condition, including trauma and stress fractures. Yet the main cause is when the foot excessively pronates, causing the big toe to push up and move towards the second toe. The 1st toe therefore stops bearing its share of the weight and the weight is transferred to the 2nd, 3rd, and 4th metatarsal heads. The first metatarsal is wider and has two sesamoids to distribute the force, but the other metatarsals are narrow, so the force is concentrated in a small area.

When the symptoms are localized in this area, we have metatarsalgia. However, as more pressure is applied on the nerve going to the toes, the sheath which protects the nerve thickens, forming a benign tumor we refer to as Mortons Neuroma. Eventually the nerve tumor becomes so large that it can no longer sit under the ligament; and, if it drifts further out between the toes, the large base of the toe bones will pinch the tumor, causing sharp pains.

This excessive pronation can be due to trauma, genetic formation, ridged big toe joint, ankle fixation, leg difference, surgery failing to give adequate results, knee deformities, drop foot due to various systemic conditions, or, more often, to tight calves. Failure to address this issue may cause other treatments to fail.

Treatment

There are several different treatments, but only one addresses the cause of the problem.

  1. For both conditions, cortisone injections can be used to calm down the inflammation, but this gives only temporary relief and does not address the mechanical problem.

  2. Shoes alone can give temporary relief for both conditions, more noticeable for metatarsalgia. In the long-term, shoes don’t solve the mechanical problem and the symptoms will increase in intensity. However, the success of the foot orthosis to achieve its goal relies on the foundation, called the shoe.

  3. Surgery is used mainly for Mortons Neuroma and consists of removing the benign nerve tumor. It should be reserved for the most severe cases because it leaves the patient with numbness, sometimes permanent, between the toes and in an area about the size of a quarter in the bottom of the foot. Numbness is not desirable but may be an acceptable tradeoff if the pain is severe.

  4. Foot Orthosis have been successful in treating both metatarsalgia and Mortons Neuroma by correcting the underlying cause: mechanical imbalance. By dropping the 1st metatarsal and redistributing the weight bearing more evenly over the entire plantar surface of the foot, the pressure is removed from the lesser metatarsals and transferred back to the 1st metatarsal. The passage of maximal force through the foot is restored to a more ideal pathway. This also takes additional pressure off the nerve. Over 90% of the clinical cases will respond favorably when treated conservatively in this way. Additionally, it has the benefit of preventing similar masses in adjacent interspaces and simultaneously rebalancing the rest of the musculoskeletal system.

  5. The majority of those with over-pronation and metatarsal pain will find a regular stretching program involving the calves/Achilles tendon and plantar fascia important to the success of all treatment. The stretching exercise at the end of this page has been recommended by the American Orthopaedic Foot & Ankle Society.

  6. Adding rockers to the bottom of the shoe(s) may provide additional reduction of the pressure on the metatarsals, after foot orthosis and stretching.

Bunions

 Normal function of the walk cycle begins at heel-strike to midfoot and ends at push-off with the big toe. There is a specific passage of force that a normal foot functions in. When the foot begins to deviate from this passage, break down occurs.

At the beginning of the walk cycle the foot contacts the ground on the outside (lateral) aspect of the heel. From this point, the passage of force then moves up the outside aspect of the foot. The weight is then distributed medially across the metatarsal heads and out through the large toe.

In a normally functioning foot, approximately 60% of the force that passes through the foot is directed through the head of the 1st metatarsal or the big toe. This is the point of contact in the gait cycle when the pressure of the foot on the ground is the greatest.

When the foot fails to function properly and excessive pronation occurs, the foot unlocks and the big toe joint is pulled to the outside by a connecting tendon called the Adductor Hallucis Tendon. As a result a bunion forms.

Symptom

Pain in the bunion area generally occurs while a person is bearing weight or wearing tight shoes. As one begins to walk, pain or burning may occur on the outside of the big toe joint and at times on the top of the joint. When pain intensifies in the bunion area, one often off-loads that area. As a result, pain occurs in the metatarsal area, on the top outside of the foot, ankle, knee, and hip.

Cause

Bunions generally develop when an excess amount of pronation occurs in the foot. The cause of pronation can be the result of trauma, genetic formation, ridged big toe joint, ankle fixation, leg difference, knee deformities, surgeries that failed to get results, various systemic conditions, or due to tightness in the calf muscles. In a pronated position, the foot becomes unlocked and as our body weight propels over an unlocked foot during the walk cycle, the 1st metatarsal joint is pushed up and inward. As this motion of the 1st metatarsal occurs, the big toe is simultaneously pulled to the outside by a connecting tendon of the adductor hallucis muscle. Repeat occurrence of this motion over time will cause the big toe to remain in this position. Once this happens the foot widens and a bump becomes visible at the base of the big toe on the inside (medial).

Improper fitting of shoe wear is the second most common reason bunions develop. When the design of a shoe is too tapered for a foot, it places excess pressure on the big toe joint. If the shoe is sized too narrow and short, over time a bunion may develop.

Finally, in rare cases, bunions have developed due to the result of trauma or a systemic disease, such as Juvenile Rheumatoid Arthritis.

Treatment

There are several methods for treating bunions:

  1. A properly built set of orthotics is the most important conservative method used in treating bunions. They are used to prevent further development or post-surgical reoccurrence of the bunion. The orthotic supports the foot in such a way that increases direct ground contact with the big toe. Placing the big toe in such a way slightly reduces the severity of the bunion.

    In a case where the bunion is mild and also flexible, support from the orthotic may move the metatarsal bone enough and remove all discomfort. Because most bunions develop from an excessive amount of pronation, a properly built orthotic will position the foot in a more supinated, locked position as the body weight passes over the foot at midstance. This prevents the ground’s reactive force from pushing the 1st metatarsal up and inward.

  2. Properly fitted shoes are necessary to treat bunions. Precaution needs to be taken to make sure shoes are long enough and accommodate the width of each individual person’s foot. Shoes need to also be as rounded as possible in the toe area.

  3. Anti-inflammatory medications can help reduce the inflammation caused by shoe-irritation.

  4. Surgery should be a last resort and reserved for those bunions that are severe. The decision to perform surgery is based on a number of circumstances and should not be taken lightly.

  5. The majority of people who have developed bunions and who also experience over-pronation will greatly benefit from a stretching program for the calf muscle. The stretching exercise at the end of this page has been recommended by the American Orthopaedic Foot & Ankle Society.

  6. Adding rockers to the bottom of the shoe(s) may provide additional reduction of the pain in the joint, after foot orthosis and stretching.

The Diabetic Foot

 Living with diabetes means dealing with important challenges everyday, like paying close attention to the health of your feet. Luckily, therapeutic footwear has been developed to help do just that.

Recent studies show that wearing therapeutic shoes and insoles as directed can have remarkable benefits. These include:
  • Avoiding future problems like new or recurrent foot ulcers.
  • Allowing extra room for foot deformities.
  • Eliminating friction, rubbing and pressure on toes and raised areas of the foot.
  • Reducing problems associated with peripheral neuropathy (loss of feeling in the feet) and impaired circulation.
  • Helping to avoid amputation and other medical procedures.

According to the Centers of Disease Control, there were over 80,000 lower limb amputations due to diabetes in 2005 alone. Yet many may have been preventable with something as simple as a special shoe and foot orthosis.

Why Now Is Better than Later

Some readers may be wondering, “If I don’t have pain or discomfort, why should I wear therapeutic shoes and foot orthoses now?” Remember the old saying, “An ounce of prevention is worth a pound of cure.” Now, that ounce comes with incredible comfort, and, thanks to Medicare, at a reduced cost.

Medicare Coverage:
Therapeutic Shoes for Diabetic Patients

In an unprecedented move, Congress amended the Medicare statutes to provide coverage, effective May 1, 1993, for depth shoes, custom molded shoes, and shoe inserts to qualifying Medicare Part B diabetic patients.

Designed to prevent lower-limb amputations prevalent in long-term diabetic patients, this new Medicare benefit has the potential to prevent patient suffering, prolong patient life, and save money. To help qualified patients, physicians simply complete a one page form.

How Patients Qualify

The physician (M.D. or D.O.) who is managing the patient’s systemic diabetic condition must certify that:
  • The patient has diabetes mellitus.
  • The patient has one or more of the following conditions:
    • History of partial or complete amputation of the foot.
    • History of previous foot ulceration.
    • History of pre-ulcerative callus.
    • Peripheral neuropathy with evidence of callus formation.
    • Foot deformity.
    • Poor circulation.


      • AND
    • The patient is being treated under a comprehensive plan of care for his/her diabetes and he/she needs therapeutic shoes and/or foot orthosis because of his/her diabetes

The Types of Shoes That Are Covered

A qualifying patient is limited to one of the following footwear categories within one calendar year:

  • One pair of depth shoes and three pairs of inserts.


    • OR
  • One pair of custom molded shoes (including inserts) and two additional pairs of inserts.
Separate inserts may be covered under certain criteria: a shoe modification will be covered as a substitute for an insert; and a custom-molded shoe is covered when the patient has a foot deformity which cannot be accommodated by a depth shoe.

To Start the Process, Here Is What You Need To Do

For a qualified patient to receive this important preventive care:
  • The Certifying Physician must review and sign a “Statement of Certifying Physician for Therapeutic Shoes.”
    (We are providing this form here as a downloadable *Adobe PDF file. Click on the following link to download the Statement of Certifying Physician for Therapeutic Shoes. You may then print it out for your Physician.)


    • *Note: If your browser does not display Adobe PDF files, follow this link to download the latest (free) version of Adobe Acrobat Reader.

    AND
  • The Prescribing Physician must complete a footwear prescription (included as part of the downloadable "Statement of Certifying Physician for Therapeutic Shoes" provided above).
Once the patient has the "Statement" and the footwear prescription, he/she can see a pedorthist, orthotist, or prosthetist to have the prescription filled. The supplier will then submit the Medicare claim (form HCFA 1500) to the appropriate Durable Medical Equipment Regional Carrier (DMERC), keeping copies of the claim form and the original prescription and statement.

Payment of these services can come in two ways. The first way is that the supplier takes assignment and receives 80% of the allowable from Medicare directly. There are no payments required on the part of the patient. The second way is that the supplier provides the service and collects the full cost of their service from the patient. This amount is more than likely to be greater than the allowable. The patient will then receive directly from Medicare 80% of the allowable cost of the service.

At Murray’s Shoes and Murray’s Pedorthics, we do not take assignment and it will be the responsibility of the patient to pay the full amount of the services directly to Murray’s Shoes or Murray’s Pedorthics.

As of 2005, the maximum payment amounts, per pair, are not to exceed the following. Prices may be slightly lower or higher in some areas.

CHART OF ALLOWABLES

Therapeutic Shoe Bill Reimbursement

Description of Work Allowable Amount Per Pair 80% Reimbursement Amount Per Pair
Extra-Depth Shoes $118.72 $94.98
Custom-Molded Shoes $356.08 $284.86
Shoe Modifications $ 52.80 $ 42.24
Multi-Density Insert Direct Molded $ 48.44 $ 38.75
Multi-Density Insert Custom Molded $ 72.28 $ 57.82
Should the Diabetic person have only one foot, the amount allowed and reimbursed will be half the amount shown.

ICD-9 Codes

Because this benefit is available to diabetic patients only, an appropriate ICD-9 code (250.00-250.91) is required when completing the Statement of Certifying Physician.

We Will Be Happy to Assist You in Any Way

Stretching Exercise

 Tightness in the calves is considered the number one cause of over-pronation. Refer back to the section on pronation for further explanation. Over the years we have found that one’s life style and occupation require a more aggressive stretching exercise program in order to gain the necessary flexibility. Following are three stretching exercises that when performed at the proper time(s) have shown success in gaining flexibility.

  1. The Runner’s Stretch: Lean forward against a wall, placing your legs in a position as if you are walking. The back foot should be pointing straight ahead or slightly turned inwards. Lock your back knee and unlock your front knee. Gently lean into the wall until stretch is felt in the calf. Stretch each leg 15-20 seconds and repeat for five times per leg per session. Do each session 5-10 times a day. An option to this stretch would be to place the toes of one foot up against a wall or on top of a block. Walk up with back foot till a tight pull is felt in the calf of the foot on the wall or block. Follow the same number of times to stretch as above.

  2. During the day, should you be one who sits a lot, put a one inch book under your toes with your knees at a right angle. If discomfort occurs in the legs, take a break and put your feet out in front of you.

  3. Muscles stretch better when they are warm. Fill you bath or hot tub up with water as hot as possible and soak in it for about five minutes. (First check with you doctor to be sure that this is safe for you.) After warming up, stay in the water, straighten your legs and lock your knees and place a towel around your toes. Pull back for 20 seconds and let go for 20 seconds. Repeat this for 10 – 15 minutes every night before going to bed. Continue this stretch for up to 30 days.
Should you at anytime feel pain while stretching, do not attempt to force that tightness in the muscle tissue to gain a good stretch. This will come in time. Also, should you feel excessive pain by stretching so much during the day, reduce the amount in half and build up your endurance more gradually.

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