Pedorthic Advice for Keeping High-Performance Feet in Top Shape

Pedorthists have their jobs cut out for them when it comes to treating athletes, dancers, and soldiers-professionals who rely on their feet for their livelihoods, and sometimes their lives. While their jobs differ drastically, these individuals nonetheless have several common traits when it comes to the factors that influence the stress and strain that affect their feet: The owners of high-performance feet push themselves to their physical limits, have an unnaturally high tolerance for pain, don't like to admit they need help, can't or won't take time off, and generally don't want to change the way their feet have worked and benefited them throughout their careers. In short, say the experts The O&P EDGE interviewed, it's a tough group to work with. "I will humbly admit that treating any of these high-end people is a total pain in the butt, but worth it," says Steven King, DPM, CPed, with the Maui Medical Group, Hawaii. The experts we spoke with say that pedorthists who hope to work with these patients need top-quality skills, patience, and restraint if they are to help their patients effectively. "I tread lightly with my professional [athletes]," says Jeffrey S. Rich, CPed, owner and president of U.S. Orthotic Center, New York, New York. "You don't want to do too much or too little, and you have to nail it on the first go-around because there is so much riding on getting them healthy and performing." Pedorthists we spoke with who are experienced in treating patients who rely on their high-performance feet suggest the following key tips for treating similar patients: Understand your patient and the rigors his or her feet experience. Convince your patient to accept your help. Make changes slowly to prevent any negative effects on the patient's performance. Ensure that the patient wears the right shoes at all times. Understanding the Patient When it comes to treating high-performance feet, a big part of the challenge for pedorthists, experts say, is understanding their patients. That comprehension is multifaceted: It means understanding the kind of shoes they are required to wear for their jobs, the movements they make, what is at stake for them to get better, and even the psychological motivations that prompt them to do what they do. "Treating athletes is a very specialized part of our field as pedorthists, and we need to know who we are treating and why we are treating them," says Dane LaFontsee, CPed, assistant clinical professor at the Medical College of Wisconsin, Milwaukee. "Anything we do can change their mechanics and render them incapable of performing [in] the way [in which] they are expected. We can't just pretend we know what's going on because we read it in a book. We need to really know what's going on." He says to appreciate the complexity of the foot issues confronting these patients, pedorthists need to understand the stress that the patients are putting their feet through and treat them individually. "I don't think I've [ever] made two alike pairs of orthotics," he says. To meet each person's unique needs, LaFontsee asks new patients to demonstrate the position in which their bodies or feet hurt the worst. Then he goes to a room by himself and puts himself in that same position to analyze what his feet are doing. "You need to study what the athlete actually does with his body," LaFontsee says. "You can't just jump in. You have to study, watch, and listen." Knowing what they do and how they move is so important that he tries to get that information even before he sees them for the first time, so he can study the sport, he says. "I want to know what sport they are in, track and field, lacrosse, a horse rider. I want to know what they can do so I can study it and know what kind of moves they do before I see them," he says. "I may not know how a lineman moves differently than a fullback, but I will study it before the athlete comes in." [caption id="" align="alignright" width="300"] Photograph courtesy of Matt Schroepfer.[/caption] The Intrinsic ballet slipper by MDM Dance contains a small orthotic sewn into the shoe (see the bright pink internal area), which works to support dancers' lower leg muscles, foot, and arch. This technology is also being used in jazz shoes to provide dancers with additional foot protection. Along with understanding the physical demands, pedorthists need to understand what motivates their patients with high-performance feet and how to treat them within the confines of those motivations, the experts say. In many cases, that means coming up with a treatment that is different from the recommendation for a typical patient who does not rely on his or her feet for his or her profession. For example, repetitive stress injuries are common among dancers, says Matthew Schroepfer, CPed, president of the dance footwear company The Fair, also known as Dancing Fair, Roseville, Minnesota. "Of course the best way to treat that is to step back and rest," he says. "But most [dancers] are independent contractors, and if they are out of work, they have no income. Their feet are their tools and their livelihoods." Schroepfer says if he hopes to help them, he knows that he has to do it in a way that allows them to keep dancing as much as possible. Part Pedorthist, Part Psychologist When it comes to treating high-performance feet, part of the challenge for pedorthists is convincing their patients to accept their help. That can be difficult, the experts acknowledge. Many times these patients have such a high tolerance for pain and push their feet so hard that by the time they show up for treatment, there is already a great deal of damage. "They charge on regardless of the condition of their feet," says Howard Hillman, CPed , owner of Signature Custom Orthotics, Brighton, Colorado. "They can make things much worse." To help these patients, the experts say they have to act like sports psychologists. "With elite athletes, their tolerance for pain is so acute that by the time I get them, they are in absolute trouble," LaFontsee says. "[T]hey probably had to sit out for a few games, and they are distressed and scared, and they want you to fix them now. I usually get them when they are in distress, both mentally and physically." To convince the patient to take the help, trust is essential, LaFontsee says. "You have to treat their heads and give them confidence that it will work and that, while it won't be an immediate fix, they need to give it time," LaFontsee says. "You have to ask questions. You work with confidence, you explain everything you might be doing and why. It's the only way you are going to gain their confidence and they will use you as a practitioner." It helps to work with the athlete's trainers and team physicians and have everyone on the same page so the athlete/patient hears the same message from everyone, he says. Still, it can be tough to get the patient to listen, experts say. "Some of them have excelled for so long, but as they get older their bodies start showing signs of wear and tear," Rich says. "It's not something they've dealt with before, and they are sometimes reluctant to accept the help they need." King says that pedorthists need to know just how much they can push their patients with their treatments and when they need to back off. "You can always come up with a treatment or a 'pill' for someone," he says. "But if the pill is too big to swallow, they won't take it and your treatment will not work." To help convince them, Rich says, he will sometimes play off of their own motivations. For these patients, that means warning them that injuries can shorten their careers and about the monetary hit that might come with that. "If you tell them, 'this will take a year off of your game,' that's how I have to get through to them," Rich says. "I let them figure out how much that will cost them." Make Small Changes The top rule for pedorthists treating high-end feet seems obvious, but is often the toughest to pull off: Don't mess anything up. That often means providing less orthotic support and making smaller changes than a pedorthist would normally provide a typical patient. "When I'm helping the general population, I'm helping them ambulate," LaFontsee says. "When I'm working with an elite athlete, I have to make darn certain that I'm not taking their livelihood away from them." These patients have trained their bodies and feet to work in a certain way, and any change, no matter how subtle, can damage their overall performance, LaFontsee says. Even patients who have bad biomechanics or have been wearing too-tight shoes for their entire careers can't go through too many changes, he says. "Even if they have bad alignment, they became elite athletes and taught their body how to function with that alignment," he says. "We can't walk in and say 'you have bad biomechanics,' because if you change too much, you might change how they became elite in the first place." For that reason, LaFontsee says, you have to make sure that any changes you make are done incrementally. "With an elite athlete, you may have to ease them into it. It may be a two-step correction or it may be a three-step. If you go too fast, it changes the way the foot hits the ground for that athlete and they lose their edge, and that's how they get paid." If that happens, then it won't matter if you can help them or not, Hillman says. "These athletes have gotten to the level they are at with the feet they were given by God," he says. "If we try to bring them into perfect biomechanical position, quite possibly they can't even tolerate what we've done for them. The key is getting them to wear the device. If it's not comfortable, they aren't going to wear it." Rich says that many of his basketball players have foot problems that would typically require a robust orthotic. However, he knows if he asks them to change too much, their playing might suffer. "Unlike the general population, with these guys you have to be very careful of not giving them too much support," Rich says. "Generally they don't like playing in orthotics. They have never worn orthotics, and by the time I get them, they've been playing the same way for 15 to 20 years." His solution is to slowly work them up to the orthotic they need, giving them time to get used to performing with each small change. "Every time you see them, you can give them more and more of a correction, but you have to do it subliminally," Rich says. "If I made a device and it's too supportive, they won't wear it, and they won't come back." One of the best ways to help these patients without hindering their performance is to have them focus on their foot health during their downtimes, LaFontsee says. "With elite athletes, you don't look to treat them when they are in performance, you treat them when they are resting," he says. After a Milwaukee Brewers pitcher had a bad game while wearing the orthotics LaFontsee made for him, he told the pitcher not to wear them during games. "He wore them when he was running and doing anything but pitching," LaFontsee says. [caption id="" align="alignright" width="300"] Bird's eye view of a dynamic full-length orthosis, which transfers energy from heel contact through the gait contact phase with the use of multiple simple machines (i.e. lever, incline, and decline planes) in a closed kinetic chain. Photograph courtesy of Steven King.[/caption] Rich says he often uses the same strategy with the basketball players he sees. If they are wearing shoes that are too small, they've likely been wearing the wrong size shoes since they were children and only know how to play well in tight-fitting shoes. He supports their need to play in them even if it's not what's best for their feet, he says. "I will compromise with them on their game shoes-they want that snugness there," he says. "But I tell them, 'in your everyday shoe, you have to get a bigger size.'" Using the Right Shoes Most of the experts will tell you that they inwardly cringe if they hear about their high-performance patients wearing nonsupportive flip-flops. "You don't want athletes to get through a football practice and then put on a pair of flimsy flip-flops," says Donna Robertson, CPed, MS, ATC, who owned Pedorthic Care Center, Hoover, Alabama, until retiring from the practice, and is now a consultant for Foot Solutions, headquartered in Atlanta, Georgia. "Their foot is already stressed and then they put on an inappropriate shoe. With the loss of structural support, when that foot has been fatigued, it does not have the recovery time it needs, and that can lead to further stress-related issues involving the musculature and joint stability." LaFontsee says that one of his toughest jobs is convincing his patients to protect and take care of their feet at all times. But if it's not possible to do so in performance, then at least do it the rest of the time. "Their foot is their tool for them to do their job," he says. "They need to protect their foot at all times as if it were a Gibson guitar or an expensive violin." For some professions, wearing supportive and comfortable footwear is almost impossible. Dancers, for example, put at least as much stress on their feet as any other athlete, yet most of their footwear has little to no protection, Schroepfer says. Schroepfer says he has developed a tap shoe with a bit more depth to allow custom orthotics inside. The shoe only allows for slim orthotics, so it will still have the same look and feel of a tap shoe, but even those slim custom orthotics can go a long way for a tap dancer, he says. "When all you have is leather and not sole, that shoe is going to break down and then when you add these intense moves from a strong dancer- it's a recipe for disaster," he says. "When a tap dancer performs, they are pounding those shoes into the ground." He also sells ballet and jazz shoes made by MDM Dance, headquartered in Hawthorn, Australia, that have small, flexible orthotics built into the shoe. According to the manufacturer, the dance base support built into the shoes is designed to support the heel and arch and to offer optimal assistance to the foot when working or resting. Schroepfer says, "It provides better support but doesn't impact the flexibility or the weight of the shoe." [caption id="" align="alignright" width="250"] A posterior view of the G.U.S. Boot, which features a patented, puncture-resistant, carbon fiber spring orthotic insole, and a standard-issue Army boot. Note the heel height difference of the G.U.S. boot, cushioned heel counter, and lack of heavy midsole. Photograph courtesy of Steven King.[/caption] Soldiers have even more trouble. Their footwear has to be flexible enough to allow them to run, but tough enough to resist external elements, such as shrapnel on the ground that can pierce the shoes, King says. In these cases, there is new technology to help, the experts say. For soldiers, King has developed a flexible and tough carbon fiber and Kevlar midsole that he believes has greater energy return than traditional foam midsoles, and he puts it in a tough boot housing. He has run multiple marathons in a prototype pair, and tested them for the U.S. Department of Defense and the U.S. Army Medical Research and Materiel Command. "We want shoes that are the most puncture-resistant, have the most energy return, and are the most stable," he says. "For a long time, minimalism made an insurgence in the shoe world. We're advocating maximalism for those with maximalist needs." For those athletes required to wear certain shoes, such as basketball players with a shoe endorsement, LaFontsee says there are still options if those shoes aren't right for their feet. If need be, he will gut the inside of the shoe and put in custom orthotics to make the shoe work for that athlete. Doing Their Best In the end, treating patients with high-performance feet tends to be an exercise in caution, the experts say. They see feet that have been put through extreme stress and pain, and yet their patient is wary of any treatment that could cause detriment to his or her career. "You just have to be more on the cautious side than jumping in and thinking you will change the world by fixing the foot," LaFontsee says. "You have got to take your time." In some cases, that means not being able to do much. With what these professionals do, and how hard they punish their feet, it's just going to cause damage, the experts say. That simply goes with the territory and, in some cases, the benefit of their chosen careers is even worth the pain, Rich says. "Some of these guys are getting paid millions of dollars for ruining their first toes," he says. And he says that he can understand that sacrifice. Maria St. Louis-Sanchez can be reached at msantray@yahoo.com

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