Our
Treatments

Our practice offers the following services to our patients:

• Comprehensive care of foot and ankle related disorders

• Surgical and non-surgical treatment of sports related athletic injuries

• Reconstructive foot and ankle surgery

• Diabetic foot care and preventative therapies

• Wound/Ulcer care

• Biomechanical analysis and functional orthotic fabrication

• Pinpointe Laser Treatment for nail fungus

• Serial casting for infants with intoeing and clubfoot disorders

• Work related injuries

 

For your convenience we have a list of common treatments with a brief description of each.

Click on a term to reveal its definition.

The foot is composed of 26 bones, with more than 100 muscles, tendons and ligaments holding these bones in place and helping them move and function.  People are born with a certain foot type spanning the field from a high arch to a low arch. They also have genetically differing types of collagen varying in degree from stretchy to firm.  With all of these variables in place, the foot is predetermined to progressively develop different deformities over time due to ambulation and movement with each step.  People with flatter feet tend to develop bunions and hammertoes whereas the high arched foot will more likely develop pain in the ball of their foot and curled hammertoes.

Bunions (Hallux Abducto Valgus)

A bunion (also referred to as hallux valgus or hallux abducto valgus) is often described as a bump on the side of the foot by the big toe. It involves structural changes in the alignment of the underlying bones, specifically the first metatarsal and the great toe.

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Over time, the first metatarsal shifts away from the lesser metatarsals.  As this is happening, the tendon that connects to the great toe tightens and pulls the great toe towards the smaller toes.  This occurs as a means of compensation to the foot’s excessive movement (or pronation). Widening of the foot helps to stabilize it and is a natural and effective measure.  Unfortunately, widening of the foot leads to bump pressure in shoe gear and pain. The malalignment of the first metatarsal and great toe joint that eventually occurs, can lead to arthritis, which also causes pain.   
Clinical symptoms range from:

• Pain or soreness, inflammation and redness

• Stiffness

• A burning sensation

• Possible numbness due to pressure on the nerve that runs right along the bump.

Diagnosis

A diagnosis is obtained by clinical examination and radiographic studies.  Clinical findings such as joint stiffness, palpable spurring, callus formation under the ball of the foot, hammertoes and a flexible flat foot are all important indictors and help determine the degree of severity and help lead to a proper treatment plan.  Because bunions are progressive, they don’t go away, and will usually get worse over time.  All people are not alike and therefore some bunions progress more rapidly than others

Treatment must be based on the patients’ age and life style. Not all people are surgical candidates and all bunion do not have to be corrected.

Non-Surgical Treatment
Early treatments are aimed at easing the pain of bunions, but they won’t reverse the deformity itself. These include:

• Changes in shoe wear. Wearing the right kind of shoes is very important. Choose shoes that have a wide toe box and forgo those with pointed toes or high heels which may aggravate the condition.

• Activity modifications. Avoid activity that causes bunion pain, including running.

• Medications. Oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be recommended to reduce pain and inflammation.

• Icing. Applying an ice pack several times a day helps reduce inflammation and pain.

• Injection therapy. Although rarely used in bunion treatment, injections of corticosteroids may be useful in treating the inflamed bursa (fluid-filled sac located around a joint) sometimes seen with bunions.

• Orthotic devices. Custom orthotic devices have not been shown to slow down the progression of bunions but theortically that makes sense. Wearing an arch support also puts more weight on the outside of the foot therefore taking weight off of the bunion area.

Surgical Treatment– see reconstructive surgery (end of section below)

Surgical procedures vary greatly depending and must depend on an evaluation of the entire foot.  Focusing solely on the bunion without taking into consideration all other deforming forces, can lead to choosing the wrong procedure, recurrence of the bunion and possible further deformities.

Metatarsal Pain- Ball of Foot Pain

Sharp pain on the bottom of the foot located just behind the toes is most commonly due to inflammation of the metatarsal-toe joints (metatarsal-phalangeal joints).  This pain is most apparent when getting up on your toes as you walk or when wearing shoes with a heel.  As the inflammation worsens, barefoot walking becomes very painful as well.  Different terms such as metatarsalgia, capsulitis, bursitis have all been associated with this condition.

 

Picture7  Picture3

 

The most common cause of this condition is an abnormal length pattern of the metatarsals.  If one metatarsal is much longer than the other four, it will bear the burden of weight bearing.  This leads to excessive stress on the ligaments that hold the metatarsal and corresponding toe together, causing the ligaments to stretch and eventually tear.  The end result is an upward shift of the toe with eventual contracture of the joint leading to a hammertoe deformity.  This then leads to more pressure on the metatarsal head and more pain in the ball of the foot or metatarsalgia.  A developing bunion can also be a cause of metatarsalgia because as the first metatarsal moves away from the second metatarsal, it shifts the weightbearing onto the second metatarsal-toe joint.

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Symptoms

• Pain, particularly on the ball of the foot. It can feel like there’s a marble in the shoe or a sock is bunched up

• Swelling in the area of pain, including the base of the toe

• Pain when walking barefoot

• Hammertoe development

In more advanced stages, the weakened ligaments lead to failure of the joint and the second toe drifts toward the big toe.  Sometimes a splay between the second and third toe is seen.  Eventually the second toe will cross over to lie on top of the big toe.  This is the end stage of capsulitis resulting in an overlapping toe.

Diagnosis

An accurate diagnosis is essential because the symptoms of capsulitis can be similar to those of a condition called Morton’s neuroma, which is caused by an enlarged nerve and is therefore treated differently from capsulitis/metatarsalgia.

In arriving at a diagnosis, the foot and ankle surgeon will examine the entire foot as well as putting the joints through a range of motion and palpating the involved area to reproduce the symptoms. The surgeon will also look for underlying causes of this problem including instability and overuse.  X-rays are usually ordered, and other imaging studies such as ultrasound and MRI may be needed to aide in a diagnosis.

Non-surgical Treatment

The best time to treat capsulitis of the second toe is during the early stages, before the toe starts to drift toward the big toe. At that time, non-surgical approaches can be used to stabilize the joint, reduce the symptoms, and address the underlying cause of the condition. The foot and ankle surgeon may select one or more of the following options for early treatment of capsulitis:

• Rest and ice. Staying off the foot and applying ice packs help reduce the swelling and pain.

• Oral medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may help relieve the pain and inflammation.

• Stretching exercises may be prescribed for patients who have tight calf muscles.

• Shoe modifications. Supportive shoes with stiff soles are recommended because they control the motion and lessen the amount of pressure on the ball of the foot.

• Orthotic devices. Custom shoe inserts are often very beneficial. These include arch supports or a metatarsal pad that distributes the weight away from the painful joint.

Surgical Treatment

When is Surgery Needed?

Once the second toe starts moving toward the big toe, it will never go back to its normal position unless surgery is performed. The foot and ankle surgeon will select the procedure or combination of procedures best suited to the individual patient.  Painful calluses under the metatarsal can develop which inhibit ambulation and sports activities.  If off-load padding and orthotics cannot control the pain associated with these calluses, then this may be another reason where corrective surgery may be necessary.

Hammertoes

A Hammertoe is a contracture (bending) of one or both joints of the second, third, fourth, or fifth (little) toes. This abnormal bending can put pressure on the toe when wearing shoes, causing irritation and callus formation.

Hammertoes usually start out as mild deformities and get progressively worse over time. In the earlier stages, hammertoes are flexible and the symptoms can often be managed with noninvasive measures. But if left untreated, hammertoes can become more rigid and will not respond to non-surgical treatment. The only conservative choice is change of shoe gear.

Because of the progressive nature of hammertoes, they should receive early attention. Hammertoes never get better without some kind of intervention.

Causes

The most common cause of hammertoe is a muscle/tendon imbalance. When one set of muscles weaken, the opposing muscles tighten causing the toe to be pulled out of alignment.

Hammertoes may be aggravated by shoes that don’t fit properly. A hammertoe may result if a toe is too long and is forced into a cramped position when a tight shoe is worn.

Occasionally, hammertoe is the result of an earlier trauma to the toe. In some people, hammertoes are inherited.

Symptoms

• Common symptoms of hammertoes include:

• Pain or irritation of the affected toe when wearing shoes.

• Corns and calluses (a buildup of skin) on the toe, between two toes, at the end of the toes or on the ball of the foot. Corns are caused by constant pressure form the shoe.

• Inflammation, redness, or a burning sensation

• Contracture of the toe

• In more severe cases of hammertoe, open sores may form.

Diagnosis

Although hammertoes are readily apparent, to arrive at a diagnosis the foot and ankle surgeon will obtain a thorough history of your symptoms and examine your entire foot. Manipulation of your joints and testing the strength and tightness of your muscles is important to help determine the underlying cause for the development of the hammertoes.  Radiographs are also necessary to see the bone structure of your foot.

Hammertoes are progressive – they don’t go away by themselves and usually they will get worse over time. Once your foot and ankle surgeon has evaluated your hammertoes, a treatment plan can be developed that is suited to your needs.

Non-surgical Treatment

There is a variety of treatment options for hammertoe. The treatment your foot and ankle surgeon selects will depend upon the severity of your hammertoe and other factors.

A number of non-surgical measures can be undertaken:

• Padding corns and calluses. Your foot and ankle surgeon can provide or prescribe pads designed to shield corns from irritation. If you want to try over-the-counter pads, avoid the medicated types. Medicated pads are generally not recommended because they may contain a small amount of acid that can irritate and even open your skin causing an infection.

• Dr. Joseph makes and sells a toe crest that helps lift the shoe off of the toe without putting pressure on the toe. It can be worn the reverse way to lift to toe off of the bottom of the shoe to prevent corns or irritation on the tip of the toes. These can be dispensed at the office if deem needed to protect your hammertoes.

• Changes in shoe wear. Avoid shoes with pointed toes, shoes that are too short, or shoes with high heels – conditions that can force your toe against the front of the shoe. Instead, choose comfortable shoes with a deep, roomy toe box and heels no higher than two inches.

• Orthotic devices. A custom orthotic device placed in your shoe may help control the muscle/tendon imbalance.

• Injection therapy. Corticosteroid injections are sometimes used to ease pain and inflammation caused by hammertoe. Too much cortisone is not a good thing and can lead to tissue atrophy.

• Medications. Oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be recommended to reduce pain and inflammation as long as there is no history of stomach ulcers or bleeding problems.

Surgical Treatment

In some cases, usually when the hammertoe has become more rigid and painful, or when an open sore has developed, surgery is needed.

Often patients with hammertoe have bunions or other foot deformities corrected at the same time. In selecting the procedure or combination of procedures for your particular case, the foot and ankle surgeon will take into consideration the extent of your deformity, the number of toes involved, your age, your activity level, and other factors. The length of the recovery period will vary, depending on the procedure

Reconstructive Surgery

If non-surgical treatments fail to relieve foot pain and when the pain interferes with daily activities, it’s time to discuss surgical options with a foot and ankle surgeon. Together you can decide if surgery is best for you.

In selecting the procedure or combination of procedures for your particular foot, the foot and ankle surgeon will take into consideration the extent of your deformity based on the x-ray findings, your age, your activity level, and other deforming forces or existing bone deformities. The length of the recovery period will vary, depending on the procedure or procedures performed. As a surgeon, one must be aware of what one is doing to one part of the foot and how it will impact the other part of the foot and the entire weight bearing surface.  The entire foot must be looked at, not just one bone, so that the correct procedures are chosen to correct deformity and not cause other problems because something was overlooked.

A variety of surgical procedures is available to treat bunions. The procedures are designed to remove the “bump” of bone, correct the changes in the bony structure of the foot, and correct soft tissue changes that may also have occurred. The goal of surgery is the reduction of pain, not to make a cosmetic perfectly straight foot.  A foot that is too straight, is a foot that will not fit into a shoe comfortably.

If a mild bunion is painful, the pain is either coming from ill-fitting shoes or the medial nerve sitting right on the “bump”. Surgical correction can be as simple as removing the bump and repositioning the nerve.  If there is any splay of the first metatarsal and increase in the angle between the first and second metatarsal, (the intermetatarsal angle), then a distal shaft osteotomy with fixation (screw or pin) can be performed.

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This same procedure can be used for a moderate bunion as well as long as the big toe position is corrected with this procedure or with an additional procedure on the toe.

More splay between the first and second metatarsals means need for procedures that tend to achieve more closure of this angle.  These procedures involve cutting the first metatarsal at the mid-shaft region.  Some of these procedures include Off-Set “V” osteotomies, “Z” osteotomies, Ludloff osteotomies, etc.  A decision is made as to which procedure best fits the patient based on bone strength, age and activity demand.

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Procedures for a severe bunion and for those people with significant flexibility and flattening of their foot, require a fusion of the metatarsal and the next bone further into the arch (the cuneiform bone) to reduce the large intermetatarsal angle and help stop further splay of the foot.

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In cases where an overlapping toe exists, the second metatarsal-toe joint and hammertoe must be corrected in order to have a good outcome with the bunion surgery.  The reverse can be true when attempting to correct a hammertoe.  If a bunion exists, the second toe hammertoe cannot be straightened without correcting the bunion, or the second toe won’t have enough room to sit down straight because the big toe will be in the way.

The metatarsal lengths must also be evaluated to make sure that they are all close to the same length.  Bunion surgery shortens the first metatarsal just in the nature of the surgery itself.  Any time bone is cut, it will lose length.  It is important to take this into consideration when performing a bunion and to add other forefoot reconstructive procedures as necessary to keep the weight bearing surface of the foot even and comfortable to walk on.

Other reconstructive procedures of the foot usually have to do with collapsed arches.  Whether the heel bone needs to be put back under the foot or the arch needs to be stabilized with a bone fusion of one or more joints is a very in depth discussion that needs to be tailored to the individual and their specific deformities and needs.

Heel Pain

Heel pain is generally the result of faulty biomechanics (gait abnormalities) that place too much stress on the heel bone and the soft tissues that attach to it. The stress may also result from injury, or a bruise incurred while walking, running, or jumping on hard surfaces; wearing poorly constructed footwear; or being overweight.

The heel bone (calcaneus) is the largest of the 26 bones in the human foot, which also has 33 joints and a network of more than 100 tendons, muscles, and ligaments. Like all bones, it is subject to outside influences that can affect its integrity and its ability to keep us on our feet. Heel pain, sometimes disabling, can occur in the front, back, or bottom of the heel.

Plantar Fasciitis

Most people think that a heel spur is the culprit causing heel pain. In truth, spurs are the result of tight tendons and ligaments that are attached to the bone. The bone is actually laying down new bone and getting rid of old bone all the time. When the ligament attached to the bottom of the heel bone is tight, it pulls on the bone causing the bone to grow in that direction, producing a bone spur. The spur is not actually cutting into anything causing pain; it is the tearing of the ligament or Plantar Fascia that causes the inflammation and resulting pain.

People who walk around barefooted at home, wear flat non-supportive shoes or sandals, or start a sport activity without appropriate stretching, are more likely to develop heel pain or plantar fasciitis. This is why arch supports which stops the flattening of the arch and the pulling of the arch ligament, stops the inflammation and pain.

Since Plantar Fasciitis is a mechanical problem, it is natural that the most effective treatment is a mechanical one; the orthotic: over-the-counter or custom, depending on the individual need of the patient.

Other treatment modalities are usually temporary but in conjunction with an arch support, are helpful. These include cortisone injections (no more than two), physical therapy, calf stretches, ice and/or temporary immobilization.

Radiographs should be taken to rule out things not seen clinically, like a fracture or a cystic lesion in the bone. Once it is established that these are not present, arch support therapy should be initiated. If pain persists after exhausting all treatment modalities, an MRI should be ordered to make sure a stress fracture not seen on a plain film does not exist. Heel pain can take time to cure and patient compliance in terms of wearing the supportive device at all times and performing the stretching exercises given, are fundamental in leading to a good outcome and speedy recovery.

Heel Spurs

Pain on the back of the heel can be caused by bone spurs that grow due to the pull of a tight Achilles tendon. Just like the spurs that form on the bottom of the heel from the plantar fascial pull, these spurs grow up the back of the heel bone and are found within the Achilles tendon. Most of the pain comes from inflammation of the Achilles tendon fibers and are not related to the spur itself. Another “bump” on the back of the heel is called a “pump bump” or Haglund’s deformity. This comes from continual rubbing of the heel bone on the back of a shoe. Excessive flattening of the foot or pronation causes this increased movement which leads to the development of this bump. It can be very painful in all closed shoes.

Treatment of the bone spurring on the back of the heel is similar to Achilles tendonitis treatment, which is outlined below. Only if the spurs become too large and thick, is surgical excision considered. This involves cutting and repairing of the tendon and has a long recovery period.

A Haglund’s deformity “bump” is treated by reducing excessive motion of the foot in the shoe with stabilizing orthotics. As a last resort, surgical excision can be performed. The bump is actually just above the Achilles tendon insertion into the heel bone and therefore little to no disturbance of the tendon fibers occurs. This leads to an easier and earlier recovery than any Achilles tendon repairs.

Achilles Tendonitis

The Achilles tendon extends down from the calf muscle and attaches to the heel bone. It is the largest and strongest tendon in the body. It is important in walking, running and standing on your toes. When the tendon is not stretched regularly or always shortened by wearing high heel shoes, injury can occur.

Abnormal walking patterns or overusing the tendon without stretching can cause the tendon fibers to form small tears that leads to inflammation and swelling. This causes pain with every step and is worse with running. The swelling is usually 1 – 1 ½ inches above the heel bone. If left untreated, a permanent bulbous swelling will occur which can lead to rupture of the tendon. Rupture can also occur without the signs of swelling in people who suddenly take up a strenuous activity without proper stretching and conditioning. Here, a sudden run or jump on a tight heel cord causes an overload on the tendon fibers and they rupture.

In order to prevent rupture, proper conditioning and slowly building up an exercise program with abundant stretching is recommended. If swelling or pain begin, visiting a podiatrist immediately to prevent a chronic condition. Excessive range of motion of the foot in walking and running can cause abnormal pull on the tendon. An arch support, custom or off the shelf, are ususally necessary to control that motion and decrease pull. A heel lift will also help reduce stress. Physical therapy is an added treatment modality to help stretch tight tendons and Ultrasound is useful in repairing tendon fibers. In chronic conditions, surgical repair of damaged fibers may be necessary. Platelet-rich plasma can also help repair tendons.

When a rupture occurs, cast immobilization above the knee is used to heal the tear in a sedentary or elderly person but surgical repair is most effective in the active patient.

Orthotics

What are Orthotics?
Orthotics are shoe inserts that are made from a cast or 3-D scan of your foot. They are intended to correct an abnormal, or irregular walking pattern. Orthotics are not truly or solely “arch supports,” but they perform functions that make standing, walking, and running more comfortable and efficient, by meeting the ground and limiting the amount of movement the foot goes through in gait whether it be walking or running.

Doctors of podiatric medicine prescribe orthotics as a conservative approach to many foot problems since many symptoms come from too much movement or overuse. Common problems like arthritis, tendonitis, plantar fasciitis (heel pain), developing bunions and forefoot pain are all related to excessive foot movement.

Orthotics take various forms and are constructed of various materials. Choosing the appropriate material for the individual patient and their specific problem is key to the success of the orthotic’s ability in decreasing symptoms.

Foot orthotics fall into three broad categories: those that primarily attempt to change foot function, those that are primarily protective in nature, and those that combine functional control and protection.

Rigid Orthotics (Functional)
The so-called rigid orthotic device, designed to control function, may be made of a firm material such as plastic or carbon fiber, and is used primarily for walking or dress shoes. The finished device normally extends along the sole of the heel to the ball of the foot. It is worn mostly in closed shoes with a heel height under two inches. Because of the nature of the materials involved, very little alteration in shoe size is necessary.

Soft Orthotics (Accomodative)
The second, or soft, orthotic device helps to absorb shock, increase balance, and take pressure off uncomfortable or sore spots. It is usually constructed of soft, compressible materials, it usually extends from the heel past the ball of the foot to include the toes. The advantage of any soft orthotic device is that it may be easily adjusted to changing weight-bearing forces. The disadvantage is that it must be periodically replaced or refurbished. It is particularly effective for arthritic and grossly deformed feet where there is a loss of protective fatty tissue on the sole of the foot. It is also widely used in the care of the diabetic feet. Because it is compressible, the soft orthotic is usually bulkier and may well require extra room in shoes, or prescription footwear.

Semi-rigid Orthotics (Sport)
The third type of orthotic device (semi-rigid) provides for dynamic balance of the foot while walking or participating in sports. This orthotic is not a crutch, but an aid to the athlete. Each sport has its own demand and each sport orthotic needs to be constructed appropriately with the sport and the athlete taken into consideration. This functional dynamic orthotic helps guide the foot through proper functions, allowing the muscles and tendons to perform more efficiently. The classic, semi-rigid orthotic is constructed of layers of soft material, reinforced with more rigid materials.

Orthotics for Children (UCBL)
Orthotic devices are effective in the treatment of children with foot deformities. These include children with severe pronation and flat feet, in-toeing gait, or partially or uncorrected clubfeet, toe walkers and children with low muscle tone. Most podiatric physicians recommend that children with such deformities be placed in orthotics soon after they start walking, to stabilize the foot. The devices can be placed directly into a standard shoe, or an athletic shoe.
Usually, the orthotics need to be replaced when the child’s foot has grown two sizes. Different types of orthotics may be needed as the child’s foot develops, and changes shape.

The length of time a child needs orthotics varies considerably, depending on the seriousness of the deformity and how soon correction is addressed.

What are Orthotics? 

Orthotics are shoe inserts that are made from a cast or 3-D scan of your foot.  They are intended to correct an abnormal, or irregular walking pattern. Orthotics are not truly or solely “arch supports,”  but they perform functions that make standing, walking, and running more comfortable and efficient, by meeting the ground and limiting the amount of movement the foot goes through in gait whether it be walking or running.

Doctors of podiatric medicine prescribe orthotics as a conservative approach to many foot problems since many symptoms come from too much movement or overuse.  Common problems like arthritis, tendonitis, plantar fasciitis (heel pain), developing bunions and forefoot pain are all related to excessive foot movement.

Orthotics take various forms and are constructed of various materials.  Choosing the appropriate material for the individual patient and their specific problem is key to the success of the orthotic’s ability in decreasing symptoms.

Foot orthotics fall into three broad categories: those that primarily attempt to change foot function, those that are primarily protective in nature, and those that combine functional control and protection.

Rigid Orthotics (Functional)

The so-called rigid orthotic device, designed to control function, may be made of a firm material such as plastic or carbon fiber, and is used primarily for walking or dress shoes. The finished device normally extends along the sole of the heel to the ball of the foot. It is worn mostly in closed shoes with a heel height under two inches. Because of the nature of the materials involved, very little alteration in shoe size is necessary.

Soft Orthotics (Accomodative)

The second, or soft, orthotic device helps to absorb shock, increase balance, and take pressure off uncomfortable or sore spots. It is usually constructed of soft, compressible materials, it usually extends from the heel past the ball of the foot to include the toes.  The advantage of any soft orthotic device is that it may be easily adjusted to changing weight-bearing forces. The disadvantage is that it must be periodically replaced or refurbished. It is particularly effective for arthritic and grossly deformed feet where there is a loss of protective fatty tissue on the sole of the foot. It is also widely used in the care of the diabetic feet. Because it is compressible, the soft orthotic is usually bulkier and may well require extra room in shoes, or prescription footwear.

Semi-rigid Orthotics (Sport)

The third type of orthotic device (semi-rigid) provides for dynamic balance of the foot while walking or participating in sports. This orthotic is not a crutch, but an aid to the athlete. Each sport has its own demand and each sport orthotic needs to be constructed appropriately with the sport and the athlete taken into consideration. This functional dynamic orthotic helps guide the foot through proper functions, allowing the muscles and tendons to perform more efficiently. The classic, semi-rigid orthotic is constructed of layers of soft material, reinforced with more rigid materials.

Orthotics for Children (UCBL)

Orthotic devices are effective in the treatment of children with foot deformities. These include children with severe pronation and flat feet, in-toeing gait, or partially or uncorrected clubfeet, toe walkers and children with low muscle tone.  Most podiatric physicians recommend that children with such deformities be placed in orthotics soon after they start walking, to stabilize the foot. The devices can be placed directly into a standard shoe, or an athletic shoe.

Usually, the orthotics need to be replaced when the child’s foot has grown two sizes. Different types of orthotics may be needed as the child’s foot develops, and changes shape.

The length of time a child needs orthotics varies considerably, depending on the seriousness of the deformity and how soon correction is addressed.

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For information on topics not discussed above click here to browse the American College of Foot and Ankle Surgery Website