Podiatry is the care of all foot problems. In children, the podiatrist is especially interested with the way the foot moves when walking and running. This is a speciality called biomechanics. The podiatrist would look at how the bones in the feet are aligned, how the joints in the feet and lower leg are synchronised and how the stability is maintained during movement so that walking is pain free and efficient.
The podiatrist is also interested in how the foot may influence pain in other joints such as the knee, hip and back. The podiatrist would also consider how footwear can improve the foot and gait and whether insoles (orthoses) in the footwear can enhance the foot function or reduce any overload on the tissues that might be causing pain.
Many healthy children have foot positions and walking styles that may be considered less than perfect, but in general, if the foot (and lower leg) is pain-free and the child can walk without fatigue for good distances, then the foot can be considered to be working well for that individual. The caveat to this is when the joint inflammation in JIA, is not fully controlled. We know that when a joint swells, the soft tissues around the joint can become stretched and, particularly in joints that take body weight – the joints can stretch into poor positions. These positions may not correct when the swelling resolves. For example, swelling around the ankle and rearfoot joints might take a normally arched foot into a flat-footed position (called a ‘pronated’ position). When the inflammation comes under control, the foot often does not correct back to its original position and so function may be impacted.
The first item in any treatment plan for any foot problem would be good footwear. For an adult or a child, the general principle is that our footwear should conform to the shape of our feet and should allow normal joint motion to occur, and be strong enough to prevent some of the abnormal movement that might be occurring. A boot will generally give more support than a shoe if the heel counter is reinforced, but the boot needs a front fastening to tighten the boot to the individual’s foot size– a side zip is not good enough.
A good shoe will have the following features:
• a strong heel counter (back) to hold the heel well.
• a front fastening so the foot is held in the strong, supportive heel counter.
• a good fit around the heel and ankle to aid stability.
• room for the toes to lie flat
• a flexible sole at the forefoot to allow the foot to rock from heel-contact to toe-off
Because everyone has different shaped feet, there is no one brand of shoe or boot that will suit everyone. It is recommended to go to a shop where the fitter is experienced so they can choose the footwear to suit the foot. A shoe shop that sells a range of brands is best so that the fitter can measure the foot and then has a wide range to choose from. Recommended brands for children’s feet include Ricosta, ECCO, Geox, Petasil, Startrite, Clarks.
High street fashion brands for school shoes are not recommended. It would be recommended that the school shoes are fitted ‘professionally’ whereas weekend shoes are less important. Even when trainers are worn to school, care needs to be taken with the fit and support they provide.
The podiatrist often uses orthoses to improve the foot position and function. Orthoses are specialised insoles that are placed into the footwear. These should conform closely to the shape of the foot and will alter the position of the heel on the leg, the forefoot on the rearfoot or they may change the timing of the movements of the foot. Orthoses are used when the foot or lower limb joints are painful, when regular swelling occurs in the foot joints or the foot function reduces efficiency of movement, or is considered to possibly cause long term problems.
There are many different ready-made brands available to the foot specialist which fit well and avoid the need to custom-make the orthoses. If the foot shape is difficult to fit, then custom made orthoses may be needed. There are several studies on orthoses in children with JIA. These studies have all found that orthoses significantly improve pain and function and quality of life measures. The ready-made orthoses are as good as custom orthoses and both are better than just footwear.
If orthoses are prescribed by a podiatrist, then new footwear may be needed at the same time. This is because the orthoses will of course take up extra room in the shoes and so a slightly different style of shoe or a larger size may be needed. Having the orthoses inn new shoes also helps the child accept the feel of the orthoses more easily.
When considering the biomechanics of the foot and lower limb, there is some overlap with the role of the podiatrist, physiotherapist and orthotist. Within all of these professions, there will be people who are very good at looking after foot mechanics. There is no evidence to say which of these professions is most successful at treating foot problems, so it will be best to ask your rheumatology consultant or team to recommend a professional to you. The podiatrist is the only professional in this group to specialise in the foot throughout their training.
Should you need to see a podiatrist, you will find that every local primary care trust has a podiatry department, but the availability of a paediatric podiatrist does vary considerably depending upon local demands and funding. Most podiatry services allow you to self-refer, and this is preferable to going through the GP who are not always fully informed on the scope of the podiatry service.
With thanks to Jill Ferrari, Senior Lecturer in Podiatry at the University of East London and Specialist Podiatrist within the Department of Paediatric Rheumatology, Great Ormond Street for sharing her expertise with us