current PPedoedoThe Officialrr Publicationtt ofhihi the Pedorthic Footcarecc Associationss
The Other Circ u lato ry System
Vol. 50, Issue 6 | November/December 2018 | www.pedorthics.org VISIT US AT BOOTH #1304
current Pedorthics
Editorial Staff COVER STORY EXECUTIVE EDITOR(S) Cover Story Christopher Costantini ASSOCIATE EDITORS Ben Nebroski ART DIRECTOR Kristopher P. Gramza DESIGN/PRODUCTION KPG DESIGN
Advertising & Sales Staff CURRENT PEDORTHICS [email protected] MEETINGS AND CONVENTIONS MANAGER Kathie Niesen EXHIBIT AND SPONSORSHIP SALES MANAGER Contact our Integrated Media and Events Manager at: [email protected]
Headquarters Staff MARKETING AND COMMUNICATIONS MANAGER Christopher Costantini MEMBERSHIP AND CONTINUING EDUCATION Tanya Rivers & Jay Zaffater 44 | CEU The Other Circulatory GOVERNMENT RELATIONS DIRECTOR System Randy Stevens By Dr. James McGuire DPM, PT, Current Pedorthics (ISSN 1552-8111) is published bimonthly by the Pedorthic Footcare Association (PFA), PO Box 72184, Albany, GA LPed, FAPWHc, Milad Manoucheh 31708-2184. Telephone: (229)389-3440 Fax: (888)563-0945 BS, Gilberto A. Vilá Arroyo Website: www.pedorthics.org Email: [email protected] In our CEU article for this edition, Dr. McGuire, Milad and Gilberto introduce Copyright© 2018, PFA. All rights reserved. No part of this publica- us to the lymphatic system, previously a tion may be reproduced in any manner without written permission. poorly understood system for returning Letters to the Editor and other unsolicited material are assumed intended for publication and are subject to editing. fluid and other materials back to the more well-known circulatory systems. This is Articles in Current Pedorthics do not necessarily reflect the opinion of important to help the body rid itself of PFA, its board of directors or its employees. Authors are responsible for infection, and to transport cellular waste. the validity of their content and credentials. Current Pedorthics’ use of trademarked names is done in an editorial fashion intended to benefit A solid understanding of this system gives the trademark owner, with no intention of trademark infringement. the pedorthist insight into the underlying causes of lymphedema, a common issue in If you have any questions regarding display advertising, please contact our daily practice. This article is available our Sales Manager at (229) 389-3440 or email: [email protected]. for Continuing Education Unit (CEU) credit. To place a classified ad, please email: [email protected]. Please send all product and industry-related press releases to: [email protected]. Cover Photo: @Shutterstock.com/CLIPAREA l Custom media
2 Pedorthic Footcare Association | www.pedorthics.org VISIT US AT BOOTH #904 / 906
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14 | Ever Evolving Waterproofing Technolog y By Melvyn P. Cheskin, MBS., C.Ped, L.Ped With the winter season fast approaching, Mel gives us a primer on some different waterproofing technologies. Help your customers make the right choice to keep from spending hours soggy-socked and miserable!
24 | Inverted Rearfoot posture in subjects with coexisting patellofemoral osteoarthritis in medial knee osteoarthritis: an exploratory study "The rearfoot affects the bio- By Hirotaka Iijima, Hiroshi Ohi, Naoto Fukutani, Tomoki Aoyama, Eishi Kaneda, mechanical alignment of the Kaoru Abe, Masaki Takahashi and Shuichi Matsuda lower limb, and therefore, it In the first of a pair of research articles (follow-up article next issue) that examine the effects of foot posture on the knee, the authors find an interesting has the potential to lead to correlation between the rearfoot position and osteoarthritis in the medial knee. As it is unlikely that knee pain or misalignment could be a causical factor in creating the rearfoot deformity, it therefore proximal diseases including stands that the rearfoot position may have caused, or at least exacerbated, the knee condition. This fact would bring this into the pedorthists’ realm of Patellofemoral osteoarthritis." treatment as the rearfoot malalignment falls within our scope of practice.
Departments
6 | From the Editor 12 | PFA News 52 | Marketplace 8 | Featured Contributiors 42 | Industry News 54 | Products & Services Photo: @iStock.com/venakrPhoto:
Current Pedorthics | September/October 2018 5 CHRIS COSTANTINI FROM THE Executive Editor EDITOR [email protected]
PEDORTHIC FOOTCARE ASSOCIATION
ABOUT PFA
The Pedorthic Footcare Association (PFA), founded in 1958, is the not-for- profit professional association which Arerepresents You the interests Following of the certified PFAand/or licensedOn Ourpedorthist Social and supports the pedorthic profession Mediaat large. Networks?
ConnectThrough PFA’s efforts,NOW pedorthics with – PFAthe management and Others and treatment in the of conditions of the foot, ankle, and lower Pedorthicsextremities requiring Community! fitting, fabricating, and adjusting of pedorthic Don’t miss out on the latest devices – is a well-established allied announcements and current health profession which makes an ello to all of you and welcome offer simple solutions to protect the topics we’re discussing on social Hto the latest edition of Current knee and reduce pain and potential mediainvaluable 24/7 contribution. to public health. Pedorthics Online. By the time inflammation. From proper shoe See what the PFA is doing today this hits your inbox, most of you selection to insoles to custom foot on Facebook, Twitter, LinkedIn, will be gearing up for the PFA 59th orthoses and braces, pedorthists google+MISSION and O and P Social for Annual Symposium and Exhibition have a lot to offer. This makes you a the latest industry and practice PFA’s mission is to enhance the in St Louis this year. We have a top valuable asset to your clients as they buzz! notch group of speakers who will strive to get and stay active and pain effectiveness and efficiency of Joincredentialed us by clickingproviders on of lowerany icon deliver informative and thought- free. You will also find a great article below! provoking presentations in the only that will enhance your understanding extremity pedorthic modalities through pedorthic-specific education event of the lymphatic system and education; increase the demand for in the nation. If you haven’t signed lymphedema, a difficult disease to services through marketing; and up, you are in the minority. Come deal with, to be sure. promote the right to practice through network and learn alongside your With Fall upon us, that means the government affairs activities. fellow pedorthists. No one ever holidays are just around the corner. goes home without some new ideas These are joyous times for most. Pedorthic Footcare Association about products, techniques, business For others, they will still be dealing approaches and some new friends! If with tremendous loss. Hurricane PO Box 72184 you haven’t already registered, stop Michael devastated the Florida Albany, GA 31708-2184 reading, go do it, and then hurry right panhandle with a level of destruction back here and finish this issue! that is thankfully rarely seen on phone (229) 389-3440 This issue features not one, but the mainland of the United States. fax (888) 563-0945 two great research articles that Many of our friends and colleagues email [email protected]&P will have immediate relevance in experienced profound loss due to website www.pedorthics.org your practice. There is a positive this storm. Count the blessings you facebook correlation between the foot and the have if you are not one of them. Our Pedorthic Footcare Association knee. Knee problems are a costly and thoughts and prayers are with you if NOTE: Often the "From the Editor" twitter ever growing issue across all walks of you were. column is an embedded video. If the image above@pfapedorthics has a "red play button", life in our society. From the athlete simply click the "play" button to start the video.linkedIn There is also included a tran- with overuse injuries to the elderly Best wishes to you all! Pedorthic Footcare Association person who feels like they are just script below for those that download a hard copygoogle+ or a printable PDF file. We wearing out, millions are spent on ■ Chris Costantini hope youPedorthic enjoy this Footcare addition to Association Current treatments and surgeries in the US Executive Editor Pedorthics and please let us know what you think!youtube Comments or Questions on each year. As a pedorthist, you can the videoPedorthic email: cpmagazine@pedor Footcare Association- thics.org. Any other inquiries email: [email protected] & p social . O&P Pedorthic Footcare Association Photo: @Shutterstock.com/VluePhoto: 6 Pedorthic Footcare Association | www.pedorthics.org VISIT US AT BOOTH #501
Full Page Ad FEATURED CONTRIBUTORS IN THIS ISSUE OF CURRENT PEDORTHICS
Melvyn P. Cheskin, MBS., C.Ped, L.Ped Mel Cheskin MBS., C.Ped is originally from England. Mel attended the University of Colorado at Boulder, CO., The School Podiatric Medicine at Temple University in Philadelphia, PA and Ars Sutoria Shoe Design College in Milan, Italy. As author of "The Complete Handbook of Athletic Footwear" and technical / medical writer for Podiatry Management, Current Pedorthics, World Footwear, Runner’s World and World Sports Activewear magazines, Mel is one of the most experienced shoe professionals in the Footwear and Pedorthic fields. In his career as a Designer and Consultant, Mel has worked for Nike (Cole-Haan), Adidas, Puma, Reebok, Brooks, Bata and Spenco Medical Corp. Mel is a Licensed Pedorthist in South Florida, residing in Boca Raton. Mel is also a member of the Bioelectromagnetic Society in Frederick, MD. and Associate member of the American Academy of Podiatric Sports Medicine.
Hirotaka Iijima, Hiroshi Ohi, Naoto Fukutani, Tomoki Aoyama, Eishi Kaneda, Kaoru Abe, Masaki Takahashi and Shuichi Matsuda This study was supported by a Grant-in-Aid for Scientific Research (grant no. 16dk0110007h0003) from the Japan Society for the Promotion of Science (https://www.jsps.go.jp/). This study shed light on the potential relationship between altered rearfoot posture and patellofemoral osteoarthritis (PFOA), as can be seen between rearfoot abnormality and patellofemoral (PF) pain.
Consider Writing an Article for Current Pedorthics! For more details, contact Current Pedorthics magazine at (229) 389-3440 or by email at: [email protected] for additional upcoming special interest topics, guidelines and other ideas you may want to discuss as topic ideas beneficial to health care, patient care and all areas of interest in the pedorthics practice and other associated industries.
8 Pedorthic Footcare Association | www.pedorthics.org James McGuire, DPM, PT, CPed, FAPWHc Dr. James McGuire is a Doctor of Podiatric Medicine, Physical Therapist and a C. Ped., as well as PFA’s current Medical Advisor. Dr. McGuire had the total experience in Podiatric Medicine and Wound Care having started and managed the development of a very busy and very successful private practice in Rutland, Vermont where he served as the State Podiatry Association Secretary, Treasurer and President, and the State Medical Board Representative. He also represented Vermont in Washington D.C where he had the opportunity to meet with lobbyists and elected representatives. After moving to Philadelphia in 1992, Dr. McGuire turned to an academic environment. He started as an instructor at the Temple University School of Podiatric Medicine and has achieved the rank of Associate Professor in the Department of Podiatric Medicine and Orthopedics. He served as department chair for many years and director of two clinical departments: Physical medicine from 1992 until 2008, and Wound Healing from 1999 until the present. Dr. McGuire lectures nationally and internationally and has become a nationally recognized expert in both podiatric medicine and wound care.
Milad Manoucheh, BA Milad is a Bachelor of Arts at Temple University School of Podiatric Medicine in Philadelphia, Pennsylvania.
Gilberto A. Vilá Arroyo Gilberto is associated with Temple University School of Podiatric Medicine in Philadelphia, Pennsylvania.
Current Pedorthics | November/December 2018 9 VISIT US AT BOOTH #403
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PFA's 59th Annual Please keep in mind that the current policy allowing you to only receive credit once for any particular online continuing educa- Symposium & Exhibition - tion opportunity is still in effect. Therefore, if you’ve taken a SEE YOU THERE! Current Pedorthics article–related quiz in previous years and received the one credit, you may not take the same quiz again to receive the two credits. PFA SYMPOSIUM WEBSITE: We hope to see everyone at the 59th Be sure to take advantage of this new opportunity for double Annual Symposium & Exhibition on November 15-18th in credits. We hope this change helps make earning your required St. Louis, Missouri. CEUs quicker and easier. PFA’s Symposium and Exhibition is a unique and out- standing educational experience, not only because of the tremendous quality of programming and speakers, but PFA's 2019 Media Kit - also the intimate, collegial atmosphere promoted. AVAILABLE NOW! So check out the updated Program and Speakers and For Immediate Release: save the date! More information will be coming soon! For more information see ad this issue and view the 59th Current Pedorthics Magazine / PFA Symposium Video Promo (see pg.1)! 2019 Media Kit will be available soon! PFA offers targeted media outlets to help you reach your (Click the link to visit symposium website): audience, maximize your return on investment and www.pedorthics.org communicate with the industry. Choose from Current Pedorthics Magazine, PFA E-Blast email announcements & PFA’s website. PFA introduces "Ask the For more information and downlod the current 2018 Media Kit (click the link): Experts" Program www.pedorthics.org/?page=CurrentPedorthics EFFECTIVE March 1st: The Pedorthic Footcare Association is proud to introduce our newest member benefit, our Ask Accepting article the Experts program! This program allows our member- ship access to a panel of experts that they can ask ques- submissions tions or advise on a number Pedorthic and clinical topics. For Immediate Release: All our experts are experienced business owners and have been in the industry for 10 years or more. To access this Current Pedorthics Magazine is now accepting article sub- member benefit, simply call the PFA office at (229) 389- missions on the following subjects: Geriatrics, Pediatrics, 3440 and select the prompt that best describes your ques- Business & Practice Management, Sports Pedorthics, Retail tion or concern. Pedorthics, Education & Research.
(See: pg.42) Submit to: [email protected]
ABC Updates CEU Credits
ABC is pleased to announce that quizzes related to Current Pedorthics magazine articles passed after January 1, 2017 will now be grant- ed two credits! Any quizzes already submitted or added to your ABC record after January 1, 2017 will be retroactively increased to two credits.
12 Pedorthic Footcare Association | www.pedorthics.org 1.888.937.2747
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Current Pedorthics | November/December 2018 13 Ever Evolving Waterproofing Technology Since the discovery of polytetrafluoroethane (PTFE), a breathable laminated waterproof film, numerous other technologies have emerged in the continuing human quest to perfect the combination of breathability and waterproofing in clothing and footwear.
BY MELVYN P. CHESKIN, MBS., C.PED, L.PED Ever Evolving Waterproofing Technology
“Waterproofing” is an easily misunderstood In contrast, waterproof fabric in accordance terminology and often confused with water to EN must demonstrate the strength to repellent and water-resistant technologies. withhold a static water column pressure at When one adds the term “Rain Proof” to the minimum 1500mm. That definitively will label, clearly a definition of terminology and not allow rain water to penetrate the fabric. testing criteria is necessary to compare and However, at that level air permeability is zero. Since the advent of plastic technologies evaluate the marketing claims of activewear in the 20th century, the challenge has brands and manufacturers. There is no been to develop fabrics that adhere to empirical data or standard testing on file the waterproof standards of laboratory in determining either “water repellency” or testing and combine those qualities with a “water resistance”. Water Repellency simply substantial degree of air permeability. means the ability of a material to repel or hinder the penetration of water and can be A common method used to protect fabric, used interchangeably with “water resistant”, including laminates, from water absorption which refers vaguely to a protective coating is treatment with Durable Water Repellent, applied to a fabric that resists water for a commonly called DWR. However, even short time. the best DWR treated fabrics can still trap
"DWR treated fabrics can still trap up to 50% of their own weight in water between the fibers. This is called ‘wet- out.’ In addition, DWR typically wears off after a few washings."
16 Pedorthic Footcare Association | www.pedorthics.org "Since its introduction in 1978, Goretex® membrane technology has set the ‘gold standard’ in breathable waterproof fabrics." https://www.thenorthface.com/shop/mens-venture-2-jacket-nf0a2vd3?variationId=7KS#hero=0
up to 50% of their own weight in water than a drop of water and 700 times bigger between the fibers. This is called ‘wet-out.’ than a water vapor* molecule. This allows In addition, DWR typically wears off after a perspiration from the body to easily few washings. evaporate through the membrane yet repel water from its surface. Goretex also GoreTex® and similar laminated advertises their technology as windproof. fabrics Encapsulated fabrics Since its introduction in 1978, Goretex® membrane technology has set the ‘gold Discovered by accident after a hot air standard’ in breathable waterproof fabrics. balloon gave its passengers a scary crash Goretex, along with other laminated landing, the inventor of this technology, a membrane technologies, is achieved by passenger on the fated trip, knew little about laminating a film to high-performance dirigibles and polymer sciences. Dirigibles textiles, then sealing them with a solution are made of strong, tightly woven and coated for guaranteed waterproof protection. synthetic fabric. The problem with that type Each microporous structure of the Goretex of material is when a substantial temperature membrane is about 20,000 times smaller difference occurs on both sides of the fabric; Photo: @iStock.com/bogdanhoria Photo:
Current Pedorthics | November/December 2018 17 Ever Evolving Waterproofing Technology
it creates a lot of stress and tension between encapsulating the fiber bundles of fabrics is the fabric and coating. that the specific silicone polymers ultimately form an ultra thin barrier layer within the Experimenting with different fabrics, he fabric making it highly water resistant and discovered that his coated fabric did not totally windproof, yet the treated fabric hold air at all. Although not suited for hot retains the natural breathing qualities, air balloons, the encapsulated fabric he was comfort and softness of the original fabric. testing did not allow water to penetrate at all but did remained air permeable. One Waterproofing is measured on the of the differences between “encapsulated” Bandusmann rain tester by the permeable waterproofing and laminated manufacturers of encapsulated fabrics. A waterproof technology lies in the definition cup is covered by the treated fabric with the of “breathable.” The laboratory test surface tilted 10 degrees from the horizontal conducted on laminated fabrics claiming position (as the shoulder slopes.) A crossbar breathability is the MVTR (Moisture Vapor constantly runs under the fabric during Transfer Rate) demonstration showing how the test to simulate body friction with rain many milligrams of water in vapor state*will falling on the fabric from a height of 1.8 diffuse through 1 square meter of laminated meters, to ensure a maximum velocity of fabric over a 24-hour period. The makers rainfall. Water repellency, absorbency and of the encapsulated technology claim that pass through are measured. The fabric is this test does not reflect natural conditions considered waterproof if it measures zero at all, as humans do not sweat water vapor rain penetration through the fabric and even at extreme bodily temperatures. We are absorbency does not exceed 20% on natural too cold to make that possible. And, even cotton and 10% on man–made fabrics. In if we were warm enough, the vapor would comparison, laminates also have a zero not stay in vapor state over 24 hours without pass through but will absorb a lot of water condensing into liquid that would reside as the fabric itself is unprotected, which inside the water proof fabric. Although means a laminated waterproof/breathable acknowledging that laminated fabrics may garment can be wet outside and inside from not leak, the manufacturers claim they do condensed perspiration. not breathe, either. The Ion Mask – Plasma Technology Encapsulated fabrics, in contrast, do not claim to achieve the same degree of A scientifically based company in the waterproof as demonstrated by the 1500 UK has approached waterproofing from mm water column test. By closing the a completely new perspective. Not only is natural gaps and cavities within the fabric, their patented plasma technology different rain water cannot penetrate into or pass because of its unique properties at the through the fabric. This is achieved with molecular level, but the process has been silicon polymer that does not react with the found to work on textiles, leather, metals and fabric fibers, so it is not melted, glued or ceramics as well. Furthermore, nanocoating laminated to the finished fabric. The idea of ion-masking treatment can be applied to the
18 Pedorthic Footcare Association | www.pedorthics.org https://www.gore-tex.com/outerwear/gorer-r7-womens-gore-tex-shakedrytm-hooded-jacket
"The fabric is considered waterproof if it measures zero rain penetration through the fabric and absorbency does not exceed 20% on natural cotton and 10% on man–made fabrics."
Current Pedorthics | November/December 2018 19 Ever Evolving Waterproofing Technology
"It is important for you to understand the pros and cons of every important feature of the footwear you provide to your clients. "
20 Pedorthic Footcare Association | www.pedorthics.org finished product, not just the materials from construction or have any particular design which it is made. For example, a finished restrictions. Can plasma treatment provide pair of shoes can be plasma treated including the answer, treating entire garments and zippers, laces, perforations included. The finished shoes so that even zippers are made process starts by inserting the object into highly liquid repellent? a sealed air reduced chamber that can hold a vacuum. Next, the ion-masking solution The breakthroughs of lamination, is pumped into the chamber in the form encapsulation and plasma waterproofing/ of a fluorinated acrylate monomer, which breathable technologies have opened the is in a liquid state at room temperature, door to potentially limitless applications. It but evaporates into a gas upon entering is important for you to understand the pros the vacuum chamber. The gas is then free and cons of every important feature of the to penetrate every fiber and coat every footwear you provide to your clients. Is the accessible surface in the chamber that allows limited breathability of a shoe protected with the plasma to attach itself to the surface of a laminated membrane good for a person the product in the final stage of the process. wearing it at work? Does the fact that they work in an environment where they are When the plasma is applied, it bonds exposed to running water all day make that to every surface of the product to form answer “yes?” It is important to be able to a nanocoating of between 10 and 60 apply the technology to the situation so your https://www.gore-tex.com/footwear/mens-alnaska-knit-low-gtxr nanometers. This has the effect of lowering customer gets the best results possible. the surface energy of an object causing oil, water and other liquids to form a -PFA spherical bead or droplet on the surface that easily rolls off under gravitational pull. The nanocoating does not change the hand or drape of any material and is three times lower in surface energy than polytetrfluoroethane. It is claimed that this waterproofing treatment is more breathable than either membrane or durable water repellent (DWR) enhancements.
As the plasma treatment allows water to roll off of seams, zippers and perforations in finished products without affecting the original breathability of the product, it would appear to have an advantage at least over membrane technology, which tends to build up heat next to the skin. The other obvious advantage in footwear is that plasma https://www.gore-tex.com/technology/original-gore-tex-products/invisible-fit-footwear waterproofing does not require special
Current Pedorthics | November/December 2018 21 VISIT US AT BOOTH #410 / 510
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Inverted Rearfoot posture in subjects with coexisting patellofemoral osteoarthritis in medial knee osteoarthritis: an exploratory study
Abstract Background: While abnormal Results: On average, patients with rearfoot posture and its relationship coexisting PFOA and medial TFOA (n=39) to patellofemoral (PF) pain has been had an inverted calcaneus 3.1° greater thoroughly discussed in the literature, its Full Page Ad Full Pagethan Ad those with isolated medial TFOA relationship to patellofemoral osteoarthritis (n=29). Increased calcaneus inverted angle (PFOA) has not been determined. This study was significantly associated with a higher aimed to examine whether rearfoot posture probability of the presence of medial PFOA is associated with a higher prevalence (odds ratio: 1.180, 95% confidence interval: of radiographic PFOA in a compartment- [1.005, 1.439]; p=0.043). Calcaneus inverted specific manner in patients with medial angle was not associated with higher odds tibiofemoral osteoarthritis (TFOA). of lateral PFOA presence based on the Methods: Participants from orthopedic adjusted values. clinics (n=68, age 56–90 years, 75.0% female), diagnosed with radiographic medial Conclusions: The presence of an inverted TFOA (Kellgren/Lawrence [K/L] grade≥2) rearfoot was associated with PFOA. were included in this study. The presence Although these findings do not clearly of PFOA and static rearfoot posture were indicate a biomechanical link between evaluated using a radiographic skyline view rearfoot posture and PFOA, this study shed and a footprint automatic measurement light on the potential relationship between apparatus, respectively. The relationship altered rearfoot posture and PFOA, as can between rearfoot posture and PFOA was be seen between rearfoot abnormality and examined using analysis of covariance and PF pain. propensity scoreadjusted logistic regression analysis.
By Hirotaka Iijima1,2,3*, Hiroshi Ohi4,5, Naoto Fukutani2, Tomoki Aoyama2, Eishi Kaneda6, Kaoru Abe4, Masaki Takahashi1 and Shuichi Matsuda7 Inverted‘A Rearfootgood fit?’ posture
Background and femoral internal rotation, subsequently resulting in higher lateral PF cartilage stress Knee osteoarthritis (OA) is the leading cause due to increased knee valgus and quadriceps of knee pain and disability worldwide [1]. angle [15], although this has not proven yet. The Patellofemoral (PF) osteoarthritis (PFOA) is an relationship between altered foot posture during under-recognized, yet important, subgroup gait and PF pain was thoroughly discussed in of knee OA [2, 3]. Depending on the source the literature [16] and rearfoot abnormalities population and definition of OA, PFOA is present may be associated with PF pain [17]. The clinical in 32–57% of adults [4] and commonly occurs in symptoms and functional limitations between combination with tibiofemoral (TF) OA (TFOA) PFOA and PF pain in adolescents and young [5–7]. The risk factors in OA pathogenesis vary adults [2, 18] are similar, and approximately 70% according to the affected compartment [8–10] of cases have radiographic PFOA in subjects and targeted interventions for PF joint disease (aged >40 years) with PF pain [5]. Therefore, it is are required owing to the unique biomechanics possible that an altered rearfoot posture would of the PF joint [2, 11]. However, the factors that be modifiable factors associated with PFOA, as contribute to its development and the effective can be seen between rearfoot posture and PF management of this common and potentially pain. Although foot orthoses were effective in debilitating condition [3] have not been improving anterior knee pain in patients with elucidated. isolated lateral PFOA [19], we are not aware of any studies that investigated the relationship The rearfoot affects the biomechanical between rearfoot posture and PFOA. alignment of the lower limb [12, 13], and therefore, it has the potential to lead to Static rearfoot posture can be easily evaluated proximal diseases including PFOA [14]. Tibeiro in the clinical setting without sophisticated et al. hypothesized that excessive eversion equipment and has been used in assessments of the rearfoot can lead to increased tibial of patients with PF pain [20]. Investigating
"The rearfoot affects the biomechanical alignment of the lower limb, and therefore, it has the potential to lead to proximal diseases including Patellofemoral (PF)
osteoarthritis (PFOA)." @Shutterstock.com/BigBlueStudio Photo:
26 Pedorthic Footcare Association | www.pedorthics.org Inverted‘A Rearfootgood fit?’ posture
rearfoot posture in patients with coexisting both patients with bilateral and unilateral PFOA may assist clinicians to better understand radiographic knee OA were included in this the effect of rearfoot posture on PF pathology study. The exclusion criteria were: (i) a history and may add to the limited evidence of studies of knee surgery, (ii) inflammatory arthritis, (iii) with PFOA population. Thus, this study aimed periarticular fracture, (iv) current neurological to examine whether altered static rearfoot problems, or (v) lateral TFOA. Lateral TFOA posture is associated with higher prevalence was defined as a knee having a K/L grade≥1 of radiographic PFOA in patients with medial along with joint space narrowing (JSN) >0 in TFOA in a compartment-specific manner. Such the lateral compartment with JSN=0 in the a relationship would indicate the existence of medial compartment [23]. In other words, only a biomechanical association, necessitating a patients who had a more severe radiographic prospective cohort study to find modifiable risk disease in the medial compartment compared factors for the incidence and progression of to the lateral compartment (i.e., isolated medial PFOA. TFOA or mixed medial and lateral TFOA) were Methods included in this study. Since medial and lateral knee OA have distinct characteristics [24], and Participants most knee OA is the medial type in Japan [25, 26], lateral TFOA (i.e., lateral OA severity > Participants of this exploratory study were medial OA severity) was excluded in this study. recruited from the 12-month follow-up period The Ethical Committee of Kyoto University of a prospective cohort of subjects described in a previous study, which investigated the approved this study (approval number: E1923). clinical impact of coexisting PFOA in patients Written informed consent was obtained from all with medial TFOA [21]. Briefly, 143 patients participants at baseline and at 12 months follow- with medial knee OA were recruited from up. a community orthopedic clinic in February Radiographic PF joint disease severity 2014 and were followed up for 12 months. The patients, diagnosed by their attending physician, The radiographic data of the lateral and were recruited through advertisements and skyline views at baseline were obtained followed up for 12 months. The inclusion criteria from all participants. If clinical symptoms were (i) age≥50 years; (ii) radiographic OA worsened within the 12-month follow-up period, (i.e. Kellgren/Lawrence [K/L] [22] grade≥2) participants underwent repeat radiography. primarily in the medial TF compartment in Detailed methods of radiographic evaluation of one or both knees, as evaluated by weight- disease severity in the PF joints were described bearing anteroposterior radiographs; and elsewhere [21]. Briefly, a single trained examiner (iii) the ability to walk independently on a (HI) assessed radiographic severity for the PF flat surface without any ambulatory assistive joint using the K/L grading system adapted to device. Subjects at baseline were included if the lateral and medial facets of the PF joint. they had medial TFOA, regardless of PFOA Presence of PFOA was defined as knee with status. No restriction was imposed on laterality; K/L grade 2 in skyline view or osteophytes 1
Current Pedorthics | November/December 2018 27 Inverted‘A Rearfootgood fit?’ posture
in lateral view. We have previously reported 0.36 mm (accuracy ±0.2%) and 0.51–1.22 mm excellent intra-rater reliability for such (accuracy ±0.5%), respectively [29]. radiographic evaluation (Kappa: 0.80) [21]. Prior to each capture session, the patient was Static Rearfoot posture asked to stand on bare feet with shoulder-width apart. This allowed 50% of their body weight Static foot posture was evaluated in January to be placed on each foot during assessment. 2015 using a three-dimensional automatic footprint measurement apparatus (CUTE, Round, black seal markers, which corresponded JMS-2100CU; Dream GP Inc., Osaka, Japan) to 2 anatomical landmarks (i.e., bottom of the [27, 28]. This foot scanning system is based on calcaneal tuberosity and enthesis of the Achilles laser line triangulation, where the measuring tendon) to detect foot alignment, were attached head moves around a single foot in an oval- to the skin (Fig. 1). After the measurements, foot shaped trajectory [29]. The laser scanner length and calcaneus inverted angle relative to rotates around the patient’s foot and measures the floor were automatically calculated by the more than 30,000 points, including the ankle, system according to the attached round black instep, heel, toes, as well as the sole, thereby seal markers. As a clinical frame of reference, precisely re-creating the patient’s foot shape. calcaneus inverted angle relative to the floor This scanning system has a high accuracy for were categorized based on value of foot posture measuring foot posture. The measurement index subcategory “inversion/eversion of the errors of foot length and foot width are − 0.27- calcaneus” [30] as follows: everted calcaneus Photo/Illustration: Provided the by authors Figure 1: Measurement of calcaneus inverted angle relative to the floor (q). Calcaneus inverted angle relative to the floor was automatically calculated by the system according to the attached round black seal markers (a bottom of the calcaneal tuberosity; b enthesis of the Achilles tendon).
28 Pedorthic Footcare Association | www.pedorthics.org Inverted‘A Rearfootgood fit?’ posture
(calcaneus angle ≤−5°); normal calcaneus (−5° 143 patients were < and≤5°); and inverted calcaneus (calcaneus initially recruited angle >5°). Throughout the manuscript, “inversion/eversion” indicates posture on a Excluded (n=75) single frontal plane, which is a part of triplane motion “supination/ pronation”. üLoss of follow up for non-specific reasons Covariates (n=41)
Data on age, sex, and height were self- üMissing data (n=34) reported by patients. Patients wearing clothes without shoes were weighed on a scale. Body mass index (BMI) was calculated by dividing Knee with K/L grade ≥ 2 in the weight by height squared. Radiographic the medial compartment: n=68 medial TFOA severity and anatomical axis angle (AAA) with sex-specific correction [31] were assessed in the anteroposterior short view in Coexisting any Isolated TFOA* the weight-bearing position. The intra-rater PFOA* (n=38 knees) (n=30 knees) reliability was excellent for evaluating the TFOA K/L grade (Kappa: 0.80) and measuring the
AAA (intra-class correlation coefficient [ICC]: Figure 2: Flowchart showing the inclusion of participants 0.98). Varus thrust was evaluated according in the study. *Presence of PFOA was defined as knee to previously described methods [32, 33]. Two with K/L grade 2 in skyline view or osteophytes 1 in physical therapists judged the presence of lateral view [21] based on baseline radiography. If clinical lateral movement of the tibial tuberosity relative symptoms worsened within the 12-month follow-up, to hip and ankle. This resulted in an increase participants underwent repeat radiography that is used in varus alignment during initial contact with for evaluation of the PFOA presence. the mid-stance of the stance phase with self- selected speed. We have previously reported good interrater reliability (Kappa: 0.73) for evaluating varus thrust assessment [32, 33]. A one knee per patient was analyzed, which trained physical therapist passively measured was designated as the “index knee.” The index the flexion and extension range of motion (ROM) knee was defined as the more painful knee in of the affected knee joint through standard the present or past. Descriptive statistics were goniometric procedures according to previously calculated as mean and standard deviation validated methods [34]. (SD) for continuous variables and as proportion Statistical analyses for dichotomous/categorical variables. We performed univariate analysis using Student’s To minimize any bias produced by similarities t-test for parametric continuous variables and between the knees of the same patient, only Fisher’s exact test for dichotomous/categorical
Current Pedorthics | November/December 2018 29 Inverted‘A Rearfootgood fit?’ posture
variables and compared the differences in Table 1: Patients’ characteristics at follow up period (n = 68)a rearfoot posture between knees with and Age, years 74.69 ± 7.785 without PFOA. Subsequently, the values of calcaneus inverted angle were compared using Female, no. (%) 51 (75.0) analysis of covariance. Covariates included age, Body mass index, kg/m2 24.14 ± 3.753 sex, BMI, TF joint K/L grade, corrected AAA, presence of varus thrust, and knee flexion ROM. Corrected anatomical axis angle, degrees 176.2 ± 4.951 These covariates were chosen based on clinical Presence of varus alignment, no. (%)a 55 (80.9) judgment and previous studies investigating factors associated with PFOA or rearfoot Medial tibiofemoral joint K/L grade, no. (%)b posture [21, 35–37]. The normality of calcaneus Grade 2 48 (70.6) inverted angle was assessed using the Shapiro- Wilk test and the homogeneity of the variances Grade 3 11 (16.2) between patients with and without PFOA was Grade 4 9 (13.2) confirmed using the F-test. Presence of varus thrust, no. (%) 12 (17.6) We further performed multiple logistic regression analyses and calculated odds ratios Knee range of motion, degrees (ORs) and their 95% CIs. Logistic regression Extensionc −6.471 ± 6.482 analyses were performed first with an unadjusted model and then with a propensity Flexion 140.8 ± 12.17 adjusted model. Due to the small sample size, Presence of any PFOA, no. (%) 38 (55.9) we used propensity score adjustment including the above covariates. Data analyses were Presence of mixed PFOA, no. (%) 19 (27.9) performed with JMP Pro 12.2 (SAS Institute, Presence of medial PFOA, no. (%) 22 (68.8) Cary, NC, USA). P-values <0.05 were considered statistically significant. Presence of lateral PFOA, no. (%) 26 (32.4)
Results Coexisting medial TFOA and any PFOA, no. 38 (55.9) (%) Figure 2 shows flowchart describing the d inclusion of study participants. One-hundred- Calcaneus inverted angle, degrees −0.357 ± 5.522 forty-three patients with medial knee OA K/L grade: Kellgren/Lawrence grade; PFOA: patellofemoral osteoarthritis; were enrolled at baseline period (February TFOA: tibiofemoral osteoarthritis 2014). Of these patients, 75 were excluded Except where otherwise indicated, values are mean ± SD from this study; 41 could not be contacted or a Varus alignment is defined as corrected anatomical axis angle < 179 declined follow up for non-specific reasons; degrees b If participants did not get worse their clinical symptoms within the and 34 were excluded because of missing 12-month follow-up period, radiography at baseline was used for K/L grade data on patient’s characteristics, radiography, assessment c and rearfoot posture at the 12 months follow A negative value indicates that the knee is flexed d up period (January 2015). Thus, our final A positive value indicates inversion direction of the calcaneus
30 Pedorthic Footcare Association | www.pedorthics.org Inverted‘A Rearfootgood fit?’ posture
sample included 68 patients (47.6% of the knees with and without PFOA. Calcaneus initial cohort) at 12 months follow-up period. inverted angle in patients with coexisting PFOA Baseline characteristics were compared was higher than those with isolated TFOA between included and excluded patients, and (1.046±5.053 vs. -2.245±5.648; p=0.014). Patients no significant differences were found between with coexisting PFOA on average had an the two groups in terms of demographic inverted calcaneus 3.1° greater than those with characteristics and radiographic disease isolated medial TFOA after adjusting for age, severity at baseline period (data not shown). Of sex, BMI, TF joint K/L grade, corrected AAA, the 68 patients who completed the study (age presence of varus thrust, and knee flexion ROM 56–90 years; 75.0% female), 48 (70.6%) had mild (p=0.047). Patients with coexisting PFOA had a diseases with K/L grade=2 in their index knee higher prevalence of inverted calcaneus (15.4% (Table 1). Thirty-eight (55.9%) of these patients vs. 6.9%) and lower prevalence of everted had PFOA. calcaneus (12.8% vs. 27.6%), although these Table 2 shows the comparison of calcaneus calcaneus alignments did not significantly differ inverted angle and calcaneus alignment in between the two groups (p=0.218).
Table 2: Comparison of calcaneus inverted angle and calcaneus alignment in knees with and without PFOA (n = 68)
Coexisting Any Isolated TFOA Variables PFOA (n = 38 p-value† Difference in mean (95% CI)†† p-value (n = 30 knees) knees)
Calcaneus inverted 1.046 ± 5.053 −2.245 ± 5.648 0.014 3.109 (0.037, 6.181) 0.047 angle, degrees §
Calcaneus alignment, no (%) §§ 0.218
Everted calcaneus 5 (13.2) 8 (26.7)
Normal calcaneus 27 (71.1) 20 (66.7)
Inverted calcaneus 6 (15.8) 2 (6.7)
PFOA: patellofemoral osteoarthritis; TFOA: tibiofemoral osteoarthritis; 95% CI: 95% confidence interval Except where otherwise indicated, values are mean ± SD † Based on Student t-test (calcaneus inverted angle) and the Fisher’s exact tests (calcaneus type) between two groups †† Adjusted for age, (continuous), sex (0: male, 1: female), body mass index (continuous), tibiofemoral joint Kellgren/Lawrence grade (continuous), corrected anatomical axis angle (continuous), presence of varus thrust (0: absence, 1: presence), and knee flexion range of motion (continuous) § A positive value indicates inversion direction of the calcaneus. §§ Inverted calcaneus: calcaneus angle ≤ − 5 degree; normal calcaneus: −5 degree < and ≤ 5 degree; everted calcaneus: calcaneus angle > 5 degree. Bold type represents a statistically significant result
Current Pedorthics | November/December 2018 31 Inverted‘A Rearfootgood fit?’ posture
Table 3: Results of binary logistic regression analysis of the association between calcaneus inverted angle and the presence of PFOA (n = 68)
Odds ratio (95% CI)* Independent variable Dependent variable Crude model Propensity adjusted model
Calcaneus inverted No PFOA (n = 30) vs. ANY † † L angle, per degrees 1.118 (1.018–1.245) 1.134 (1.013–1.291) adies’ PFOA (n = 38)
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Inverted calcaneus 6 (15.8) 2 (6.7)
PFOA: patellofemoral osteoarthritis; 95% CI: 95% confidence interval *Adjusted for propensity to prescribe as a function of age, (continuous), sex (0: male, 1: female), body mass index (continuous), tibiofemoral joint Kellgren/ Lawrence grade (continuous), corrected anatomical axis angle (continuous), presence of varus thrust (0: absence, 1: presence), and knee flexion range of motion (continuous) INTRODUCING LIV & ELLEN † p <0.05; †† p <0.01 Four new timelessly fashionable styles: pink, white and navy canvas, Ellen or black leather. Perfect summer footwear for women on the go! Model: A401W
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and physical function between patients with PF pain and PFOA, none of the included studies examined rearfoot posture in patients with PFOA [18]. Thus, this study is the first to show that rearfoot posture may be a potential modifiable factor associated with PF joint disease.
Excessive rearfoot eversion is suggested to lead to tibial and femoral internal rotation, subsequently resulting in increased quadriceps angle and higher lateral PF cartilage stress [15] in accordance with “law of valgus” (i.e. varus alignment increases the medial PF force and valgus alignment increases the lateral PF force) [39]. If this biomechanical theory is correct, everted and inverted calcaneus are associated with lateral and medial PFOA, respectively. This theory is supported by the significant relationship between calcaneus inverted angle and the presence of medial PFOA shown by the findings. However, calcaneus inverted angle "These findings do not clearly is likely associated with lateral PFOA given that the lower limit of 95% CI of OR is near support a biomechanical link 1.0. These findings do not clearly support a between inverted rearfoot biomechanical link between inverted rearfoot alignment and medial alignment and medial compartment-specific PFOA. Thus, inverted calcaneus may represent a compartment-specific PFOA. clinical feature of multicompartmental disease. Thus, inverted calcaneus may Further studies examining the biomechanical represent a clinical feature of link between rearfoot abnormality and PFOA are warranted to support the findings from this multicompartmental disease. exploratory study. Further studies examining the
We found that calcaneus inverted angle was biomechanical link between associated with a higher prevalence of medial rearfoot abnormality and PFOA PFOA. Conflicting evidence linking foot eversion are warranted to support the and PF exists, although excessive foot eversion and its relationship to PF pain have been findings from this exploratory
discussed in literature. For example, Powers et study." @Shutterstock.com/SebastianPhoto: Kaulitzki
34 Pedorthic Footcare Association | www.pedorthics.org Inverted‘A Rearfootgood fit?’ posture
al. found that patients with PF pain exhibited mixed OA is common [5–7] and is likely to be increased rearfoot inversion compared to more painful than those with isolated PFOA those without PF pain in younger adults when [43]. However, the observed relationship examined using a goniometer [20]. The presence between varus thrust and the presence of PFOA of both PF pain and altered foot posture can in patients with medial knee OA may not be lead to this progression given that PF pain in true for patients with isolated PFOA that was younger adults is suggested to be a precursor suggested as a precursor of mixed OA [44]. to PFOA. However, due to the cross-sectional There are some limitations to be noted. First, nature of this study, PFOA may develop first and the cross-sectional study design limits our ability altered rearfoot posture may be a consequence to identify causality between inverted rearfoot of PFOA. Bidirectional segmental relationship posture and PFOA. Second, a foot scanning has been determined among foot, shank, thigh, system was used for static measurements and pelvis [40]; therefore, a prospective cohort while standing. Evaluating dynamic rearfoot study on the incidence of PFOA in patients with alignment through three-dimensional motion inverted rearfoot but without PFOA should be capture apparatus [45] may provide substantial conducted. This is particularly important given information about the association between foot that risk factors associated with the incidence posture and PFOA with higher accuracy and and progression of PFOA have not been fully reliability than static measure [46]. Furthermore, determined. calcaneus inverted angle does not include the It should be noted that there was a large subtalar joint and may yield different values interindividual variability of calcaneus inverted compared to traditional evaluation methods angles, although patients with coexisting PFOA that use goniometers for evaluating rearfoot had an inverted calcaneus 3.1° greater than posture [47]. Nevertheless, this scanning system those with isolated medial TFOA. Understanding is advantageous because it has a high accuracy these variabilities is important because for measuring static foot posture [29] which can interventions concerning foot orthoses targeting be clinically assessed in a short amount of time. PF joint disease may lack clinical significance Third, PFOA identification using radiographs [19, 41] and evaluating individual rearfoot is an important limitation. Radiographic posture may facilitate pain reduction of foot assessment indirectly measures the cartilage orthoses. Sultive et al. found that increased and is less sensitive than MRI. This would lead to inverted calcaneus during standing is a potential differences in the prevalence of coexisting PFOA. Specifically, patients with isolated TFOA may indicator of non-success in the treatment of foot have cartilage damage in the PF joint without orthoses for improving PF pain [42], indicating radiographic evidence of PFOA. Furthermore, a substantial role for rearfoot posture on foot radiographic views might be affected by knee orthoses in targeting the PF joint. position and the patellar alignment. Fourth, this The current study included patients with study included subjects who did not undergo medial TFOA and compared rearfoot posture follow-up x-ray is an important limitation. Some in patients with and without PFOA because of the individuals who did not have PFOA at
Current Pedorthics | November/December 2018 35 Inverted‘A Rearfootgood fit?’ posture
baseline might have developed radiographic more inverted calcaneus than those with PFOA at follow-up without worsen of clinical isolated medial TFOA after adjustment for symptoms, which might affect the relationship covariates. Increased calcaneus inverted angle between rearfoot alignment and presence of was significantly associated with higher odds PFOA. Finally, this study did not account for of the presence of any and medial PFOA, and confounders of PFOA, such as the quadriceps likely to be associated with higher odds of the muscle [48] and gait kinematics [48, 49]. These presence of mixed lateral PFOA. Further studies possible confounders need to be examined are warranted to elucidate the pathomechanics further using epidemiologic studies to elucidate linking rearfoot and PF joint disease. .end. the relationship between rearfoot posture and PFOA. Conclusions
This exploratory study found that patients with coexisting PFOA on average had a 3.1°
NOTES: (1) substantial contributions to research design, or Abbreviations AAA: Anatomical axis angle; BMI: Body the acquisition, analysis or interpretation of data; (2) mass index; ICC: Intra-class correlation coefficient; K/L drafting the paper or revising it critically; (3) approval of grade: Kellgren/Lawrence grade; OA: Osteoarthritis; the submitted and final versions; and (4) agreed to be OR: Odds ratio; PF: Patellofemoral; PFOA: Patellofemoral accountable for all aspects of the work. The specific osteoarthritis; ROM: Range of motion; SD: Standard contributions of the authors are as follows: (1) Conception deviation; TFOA: Tibiofemoral osteoarthritis and design of the study: HI, HO, NF, TA, EK, and SM. Acknowledgments: (2) Analysis and interpretation of the data: HI, HO, NF, TA, EK, KA, MT, and SM. (3) Drafting of the article: HI, The authors thank Ms. Yuko Yamamoto, Mr. Masakazu HO, NF, TA, EK, KA, MT, and SM. (4) Critical revision of Hiraoka, Mr. Kazuyuki Miyanobu, and Mr. Masashi the article for important intellectual content: HI, HO, TA. Jinnouchi (Nozomi Orthopaedic Clinic, Hiroshima) for (5) Final approval of the article: HI, HO, NF, TA, EK, KA, assistance and advice. MT, and SM. (6) Statistical expertise: HI, NF, and TA. Funding: (7) Obtaining of funding: TA and SM. (8) Collection and This study was supported by a Grant-in-Aid for Scientific assembly of data: HI, HO, NF, TA, and EK. Research (grant no. 16dk0110007h0003) from the Japan Ethics approval and consent to participate: Society for the Promotion of Science (https://www.jsps. go.jp/). The ethical committee of Kyoto University approved the Availability of data and materials: study (approval number: E1923), and written informed consent was obtained from all participants before their The datasets used and analyzed during the current study enrollment. available from the corresponding author on reasonable request. Competing interests: Authors’ contributions: The authors declare that they have no competing All authors have made substantial contributions to interests.
36 Pedorthic Footcare Association | www.pedorthics.org Inverted‘A Rearfootgood fit?’ posture
Author Details: University of Health and Welfare, Niigata, Japan. 5 Ohi Manufacturing Co., Ltd., Kyoto, Japan. 6 Nozomi 1 Department of System Design Engineering, Keio Orthopedic Clinic, Hiroshima, Japan. 7 Department of University, Yokohama, Japan. 2 Department of Physical Orthopedic Surgery, Graduate School of Medicine, Kyoto Therapy Human Health Sciences, Graduate School University, Kyoto, Japan. of Medicine, Kyoto University, Kyoto, Japan. 3 Japan Society for the Promotion of Science, Tokyo, Japan. 4 Graduate School of Health and Welfare, Niigata
REFERENCES 13. Resende RA, Deluzio KJ, Kirkwood RN, Hassan EA, Fonseca ST. Increased unilateral foot pronation affects 1. Cross M, Smith E, Hoy D, Nolte S, Ackerman I, Fransen lower limbs and pelvic biomechanics during walking. Gait M, et al. The global burden of hip and knee osteoarthritis: Posture. 2015;41:395–401. estimates from the global burden of disease 2010 study. Ann Rheum Dis. 2014;73:1323–30. 14. Powers CM. The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical 2. Hinman RS, Crossley KM. Patellofemoral joint perspective. J Orthop Sports Phys Ther. 2003;33:639–46. osteoarthritis: an important subgroup of knee osteoarthritis. Rheumatology (Oxford). 2007;46:1057–62. 15. Tiberio D. The effect of excessive subtalar joint pronation on patellofemoral mechanics: a theoretical 3. Crossley KM, Hinman RS. The patellofemoral joint: the model. J Orthop Sports Phys Ther. 1987;9:160–5. forgotten joint in knee osteoarthritis. Osteoarthr Cartil. 2011;19:765 –7. 16. Barton CJ, Levinger P, Menz HB, Webster KE. Kinematic gait characteristics associated with 4. Hart HF, Stefanik JJ, Wyndow N, Machotka Z, Crossley patellofemoral pain syndrome: a systematic review. Gait KM. The prevalence of radiographic and MRI-defined patellofemoral osteoarthritis and structural pathology: a Posture. 2009;30:405–16. systematic review and meta-analysis. Br J Sports Med. 17. Aliberti S, Costa Mde S, Passaro Ade C, Arnone 2017;51: 1195–208. AC, Hirata R, Sacco IC. Influence of patellofemoral pain 5. Hinman RS, Lentzos J, Vicenzino B, Crossley KM. syndrome on plantar pressure in the foot rollover process Is patellofemoral osteoarthritis common in middle-aged during gait. Clinics (Sao Paulo). 2011;66:367–72. people with chronic patellofemoral pain? Arthritis Care Res 18. Wyndow N, Collins N, Vicenzino B, Tucker K, Crossley (Hoboken). 2014;66:1252–7. K. Is There a biomechanical link between patellofemoral 6. McAlindon T, Zhang Y, Hannan M, Naimark A, pain and osteoarthritis? A narrative review. Sports Med. Weissman B, Castelli W, et al. Are risk factors for 2016;46:1797–1808. patellofemoral and tibiofemoral knee osteoarthritis 19. Collins NJ, Hinman RS, Menz HB, Crossley different? J Rheumatol. 1996;23:332–7. KM. Immediate effects of foot orthoses on pain 7. Duncan RC, Hay EM, Saklatvala J, Croft PR. Prevalence during functional tasks in people with patellofemoral of radiographic osteoarthritis–it all depends on your point osteoarthritis: a cross-over, proof-of-concept study. Knee. of view. Rheumatology (Oxford). 2006;45:757–60. 2017;24:76–81.
8. Cooper C, McAlindon T, Snow S, Vines K, Young 20. Powers CM, Maffucci R, Hampton S. Rearfoot posture P, Kirwan J, et al. Mechanical and constitutional risk in subjects with patellofemoral pain. J Orthop Sports Phys factors for symptomatic knee osteoarthritis: differences Ther. 1995;22:155–60. between medial tibiofemoral and patellofemoral disease. J 21. Iijima H, Fukutani N, Aoyama T, Fukumoto T, Rheumatol. 1994;21:307–13. Uritani D, Kaneda E, et al. Clinical impact of coexisting 9. Cicuttini FM, Spector T, Baker J. Risk factors for patellofemoral osteoarthritis in Japanese patients with osteoarthritis in the tibiofemoral and patellofemoral joints medial knee osteoarthritis. Arthritis Care Res (Hoboken). of the knee. J Rheumatol. 1997;24: 1164–7. 2016;68:493–501.
10. Schiphof D, van Middelkoop M, de Klerk BM, Oei EH, 22. Kellgren JH, Lawrence JS. Radiological assessment of Hofman A, Koes BW, et al. Crepitus is a first indication osteo-arthrosis. Ann Rheum Dis. 1957;16:494–502. of patellofemoral osteoarthritis (and not of tibiofemoral 23. Altman RD, Gold GE. Atlas of individual radiographic osteoarthritis). Osteoarthr Cartil. 2014;22:631–8. features in osteoarthritis, revised. Osteoarthr Cartil. 11. Grelsamer RP, Klein JR. The biomechanics of 2007;15(Suppl A):A1–56. the patellofemoral joint. J Orthop Sports Phys Ther. 24. Butler RJ, Barrios JA, Royer T, Davis IS. Frontal-plane 1998;28:286–98. gait mechanics in people with medial knee osteoarthritis 12. Tiberio D. Pathomechanics of structural foot are different from those in people with lateral knee deformities. Phys Ther. 1988;68: 1840–9. osteoarthritis. Phys Ther. 2011;91:1235–43.
Current Pedorthics | November/December 2018 37 Inverted‘A Rearfootgood fit?’ posture
25. Muraki S, Oka H, Akune T, Mabuchi A, En-yo Y, patellofemoral pain research retreat, Manchester. Yoshida M, et al. Prevalence of radiographic knee Part 1: terminology, definitions, clinical examination, osteoarthritis and its association with knee pain in the natural history, patellofemoral osteoarthritis and elderly of Japanese population-based cohorts: the patient-reported outcome measures. Br J Sports Med. ROAD study. Osteoarthr Cartil. 2009;17:1137–43. 2016;50:839–43.
26. Muraki S, Akune T, En-Yo Y, Yoshida M, Suzuki T, 39. Hungerford DS, Barry M. Biomechanics of the Yoshida H, et al. Joint space narrowing, body mass patellofemoral joint. Clin Orthop Relat Res. 1979:9–15. index, and knee pain: the ROAD study (OAC1839R1). 40. Khamis S, Dar G, Peretz C, Yizhar Z. The Osteoarthr Cartil. 2015;23:874–81. relationship between foot and pelvic alignment while 27. Ohi H, Iijima H, Aoyama T, Kaneda E, Ohi K, Abe standing. J Hum Kinet. 2015;46:85–97. K. Association of frontal plane knee alignment with foot 41. Crossley KM, van Middelkoop M, Callaghan MJ, posture in patients with medial knee osteoarthritis. BMC Collins NJ, Rathleff MS, Barton CJ. 2016 patellofemoral Musculoskelet Disord. 2017;18:246. pain consensus statement from the 4th international 28. Iijima H, Ohi H, Isho T, Aoyama T, Fukutani N, patellofemoral pain research retreat, Manchester. Part Kaneda E, et al. Association of bilateral flat feet 2: recommended physical interventions (exercise, with knee pain and disability in patients with knee taping, bracing, foot orthoses and combined osteoarthritis: a cross-sectional study. J Orthop Res. interventions). Br J Sports Med. 2016;50:844–52. 2017;35:2490–8. 42. Sutlive TG, Mitchell SD, Maxfield SN, McLean 29. Fujita H, Fukumoto S, Yoshida H, Wakasugi Y, CL, Neumann JC, Swiecki CR, et al. Identification of Kano H. A 3D foot scanning system with a sensor head individuals with patellofemoral pain whose symptoms guided around the foot (Japanese). Transactions of the improved after a combined program of foot orthosis use Institute of Systems, Control and Information Engineers. and modified activity: a preliminary investigation. Phys 2004;17:330 –7. Ther. 2004;84:49–61.
30. Redmond AC, Crosbie J, Ouvrier RA. Development 43. Szebenyi B, Hollander AP, Dieppe P, Quilty B, and validation of a novel rating system for scoring Duddy J, Clarke S, et al. Associations between pain, standing foot posture: the foot posture index. Clin function, and radiographic features in osteoarthritis of Biomech (Bristol, Avon). 2006;21:89–98. the knee. Arthritis Rheum. 2006;54:230–5.
31. Kraus VB, Vail TP, Worrell T, McDaniel G. A 44. Lankhorst NE, Damen J, Oei EH, Verhaar comparative assessment of alignment angle of the knee JAN, Kloppenburg M, BiermaZeinstra SMA, et al. by radiographic and physical examination methods. Incidence, prevalence, natural course and prognosis of Arthritis Rheum. 2005;52:1730–5. patellofemoral osteoarthritis: the cohort hip and cohort knee study. Osteoarthr Cartil. 2017;25:647–53. 32. Fukutani N, Iijima H, Fukumoto T, Uritani D, Kaneda E, Ota K, et al. Association of Varus Thrust with Pain 45. Powers CM, Chen PY, Reischl SF, Perry J. and Stiffness and activities of daily living in patients with Comparison of foot pronation and lower extremity medial knee osteoarthritis. Phys Ther. 2016;96:167–75. rotation in persons with and without patellofemoral pain. Foot Ankle Int. 2002;23:634–40. 33. Iijima H, Fukutani N, Aoyama T, Fukumoto T, Uritani D, Kaneda E, et al. Clinical phenotype classifications 46. Silva Dde O, Briani RV, Pazzinatto MF, Ferrari based on static Varus alignment and Varus thrust in D, Aragao FA, Albuquerque CE, et al. Reliability and Japanese patients with medial knee osteoarthritis. differentiation capability of dynamic and static kinematic Arthritis Rheumatol. 2015;67:2354–62. measurements of rearfoot eversion in patellofemoral pain. Clin Biomech (Bristol, Avon). 2015;30:144–8. 34. Watkins MA, Riddle DL, Lamb RL, Personius WJ. Reliability of goniometric measurements and visual 47. Root ML, Orien WP, Weed JH. Normal and estimates of knee range of motion obtained in a clinical abnormal function of the foot: Clin Biomech. Bristol: setting. Phys Ther. 1991;71:90–6. Avon; 1977.
35. Englund M, Lohmander LS. Patellofemoral 48. Farrokhi S, O'Connell M, Fitzgerald GK. Altered osteoarthritis coexistent with tibiofemoral osteoarthritis gait biomechanics and increased knee-specific in a meniscectomy population. Ann Rheum Dis. impairments in patients with coexisting tibiofemoral and 2005;64:1721–6. patellofemoral osteoarthritis. Gait Posture. 2015;41:81– 5. 36. Cahue S, Dunlop D, Hayes K, Song J, Torres L, Sharma L. Varus-valgus alignment in the progression 49. Teng HL, MacLeod TD, Link TM, Majumdar S, of patellofemoral osteoarthritis. Arthritis Rheum. Souza RB. Higher knee flexion moment during the 2004;50:2184–90. second half of the stance phase of gait is associated with magnetic resonance imaging progression of 37. Iijima H, Fukutani N, Yamamoto Y, Hiraoka M, patellofemoral joint osteoarthritis. J Orthop Sports Phys Miyanobu K, Jinnouchi M, et al. Association of varus Ther. 2015:1–32. thrust with prevalent patellofemoral osteoarthritis: a cross-sectional study. Gait Posture. 2017;58:394–400.
38. Crossley KM, Stefanik JJ, Selfe J, Collins NJ, Davis IS, Powers CM, et al. 2016 patellofemoral pain consensus statement from the 4th international
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ACCESS EXPERTS IN ALL AREAS OF YOUR PROFESSION he Pedorthic Footcare Association is proud interest are important to you, our members. To Tto introduce our newest member benefit, our access this member benefit, simply call the PFA Ask the Experts program! This program allows our office at (229) 389-3440 and select the prompt membership access to a panel of experts that they that best describes your question or concern. Not can ask questions or advise on a number Pedorthic sure who to speak with, simply connect with the and clinical topics. We currently have experts to operator and you will be guided to the appropriate cover the following topics: expert. You will be immediately connected to a LIVE person ready and willing to help you get the • Clinical Practice answers to your questions. Business and Business Development Want to know who your talking too, no problem! • See our list of experts and their area of expertise in • Government Affairs the image above! • Continuing Education All our experts are experienced business owners Marketing and have been in the industry for 10 years or more. • They have a wealth of information to share with • Audit Support you, and in the event they don’t know the answers, have a vast network they can reach out too in We will be adding to our list of experts as we order to find an answer. So, don’t hesitate! Take grow the program and find out what areas of advantage of this new member benefit today!!! Call the PFA office at (229) 389-3440 & Talk to an Expert Today!
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44 Pedorthic Footcare Association | www.pedorthics.org CEU
The Other
Circ u lato ry Read This Article, Take Survey to System Earn Continuing Education Units
The Pedorthic Footcare Association (PFA) offers Continuing Education Units (CEUs), approved by the American Board James McGuire DPM, PT, LPed, FAPWHc for Certification in Orthotics, Prosthetics Milad Manoucheh BS & Pedorthics, Inc. (ABC) and the Board of Certification/Accreditation (BOC), via Gilberto A. Vilá Arroyo specially designated articles within Current Pedorthics magazine.
To take advantage of the program, thoroughly read the adjacent CEU article and then visit: www.pedorthics.org and click on the Continuing Education The lymphatic system is often referred to as the forgotten Opportunities tab to purchase the 10-question quiz associated with this article. circulatory system and is frequently an afterthought in many CEP quizzes cost $25 for members and $50 medical school curricula. The arterial and venous systems for non-members. The quizzes are worth 1.0 make up a closed loop designed to transport oxygenated Scientific or Business CEU, depending on the content. Successful completion of the blood to the tissues and deoxygenated blood back from the quiz will result in 1.0 CEP reported directly to periphery. The lymphatic system is responsible for returning ABC and BOC at the end of each quarter. fluid or transudate that escapes from the capillary vessels into the interstitial spaces back to the heart (4). In a number Look for additional CEU-eligible articles in future issues of the magazine; previous of recent broadcasts the discovery of a new organ system articles are available in the magazine archive was big news. Last year it was the omentum or mesentery at www.pedorthics.org. and this year it is the interstitium or the intricate system of connective tissue that fills the spaces between other systems. If you have any questions, contact PFA, at (229) 389-3440 or e-mail: The interstitium is intimately associated with the lymphatic [email protected]. system, its primary fluid management mechanism. It also has a major role in immunity as it collects white blood cells that leave the circulatory system to address infection,
Current Pedorthics | November/December 2018 45 The Other Circulatory System
malignancy, or injury and transports them to the that produce scarring in the tissues appreciated on lymph nodes where antibodies are made and the examination as brawny edema. immune system alerted to the threat. The lymphatic system also assists in both absorbing and transporting Marked swelling in one or more of the extremities fatty acids away from the intestinal system, as well as is the hallmark of lymphedema; although it can eliminating toxins and cellular waste (1). occur in other parts of the body such as the head, neck, breasts, genitals, and trunk. Lymphedema is One of the lymphatic system’s most important a lifelong condition without a cure (7). The various functions is to remove transudate or protein rich etiologies of lymphatic impairment can be categorized fluid from the interstitium. Flow impairment and into 2 broad types. The first type, known as primary congestion of the lymphatic system prevents the lymphedema, is a rare and genetic form that occurs from abnormal development of the lymph system. The second form, known as secondary lymphedema, occurs when there is an injury to the lymph nodes or vessels (3).
In the United States, and other developed countries, lymphedema is caused by a variety of secondary etiologies. Cardiac disease and chronic venous insufficiency are leading causes; however, infection, cancer, and chemotherapy can also cause lymphedema (2). Chronic venous insufficiency (CVI) is caused by dysfunctional valves in veins of the extremities. When the valves do not close properly, the blood is brought down by gravitational forces; this results in less venous return to the heart and more blood pooling in the extremities known as venous stasis. The increased intraluminal pressure from the excess blood in the veins (venous hypertension) pushes fluids from the veins into the interstitial tissues. As a lymphatic vessels from properly resorbing the heavier result, there is high amount of protein rich exudate in molecules, such as proteins. The residual proteins in the tissues that overwhelms the lymphatic system that the interstitium increase its oncotic pressure, which cannot return all of the excess fluid. Accumulation inadvertently causes the loss of more transudate from of excess fluid and proteins in the tissues results the vessels to the interstitium. The resulting swelling, in a type of secondary lymphedema known as or edema, is what is medically known as lymphedema. phlebolymphedema (6,7). Phlebolymphedema is the Proteins, bacteria, and toxic debris are not supposed most common type of lymphedema in the western to be in the interstitium so their presence induces an world (7). Regardless of cause, however, lymphedema inflammatory response addressed by accumulation will impact oxygen and nutrient delivery to the body of white blood cells and activation of fibroblasts causing major local and possibly systemic effects. In
46 Pedorthic Footcare Association | www.pedorthics.org artery THE LYMPHATIC SYSTEM vein
capsule
outgoing LYMPHATIC VESSEL lymph vessel
valve open
incoming valve closed lymph fluid entering vessel lymphatic lymph capillary
"...interstitium or the intricate system of connective tissue that fills the spaces between other systems... the interstitium is intimately associated with the lymphatic system, its primary fluid management
Illustraton abapted from: @Shutterstock.com/Sakurra from: abapted Illustraton mechanism."
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OM18-MKT00-7423-RevA-Select-Sheer-Sell-Sheet-Ad-PFA_r4v3.indd 1 7/26/18 11:47 AM the lower extremity it is much more of a concern than from the external environment. Partsch showed via the upper extremity (unless caused by a malignancy) standing Magnetic Resonance Imaging (MRI) that as it can lead to dermatological breakdown and using compression wear that applies 30-40 mmHg of ulceration, thus threatening the vitality of the entire pressure narrowed the diameter of the veins in the extremity (4). leg by 6-10% in the standing position (11) improving the function of the valves and increasing interstitial There is an increase in cases of lymphedema in the pressure to force fluids back into the lymphatic United States primarily because of increases in the vessels. The therapy of choice for lymphedema is general life expectancy. As we physically mature, a specialized manual massage technique called issues such as muscle weakness, decreased activity, complex or complete decongestive therapy (CDT). and degradation of collagen and vessels increase the The technique employs highly trained manual chances of the development of lymphedema (4). Along therapists that use a series of light preplanned strokes
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"The therapy of choice for lymphedema is a specialized manual massage technique called complex or complete decongestive therapy (CDT)."
with advancing age, poor management of the disease to move lymphatic fluid through available channels increases its severity. Commonly used treatments and open new channels for fluid drainage to manually for lymphedema includes using compression wraps, decongest lymphatic vessels (5). Edema reduction is stockings, segmental compression devices, and then maintained by the application of short stretch elastic stockinette to try to counteract the excess wraps reapplied at each session. lower extremity circulatory hypertension. Partsch (2016) considers venous narrowing by compression In 2002, Weiss and Spray conducted a study to see essential for treating lower extremity edema. In a if quality of life (QOL) was improved with complete faulty fluid management system to return lymph and decongestive therapy in patients who had peripheral blood to the heart, the body needs extra compression lymphedema due to various causes. Physical,
Current Pedorthics | November/December 2018 49 The Other Circulatory System
functional, and psychosocial quality of life measures During propulsion the Lycra stretches and flexes were assessed with a questionnaire administered to reduce ankle compression and allow for toe box before and after treatment. The study found that pre flex at toe off. Dodds states that Lycra is the best and post quality of life scores revealed a significant fabric available because it does not produce shearing improvement in quality of life after CDT treatment. forces on the skin seen with cheaper materials such Moreover, patients who had lower extremity as Spandex®. Lyca® easily expands thus providing lymphedema benefited more from CDT than upper ample space for the edematous extremity and extremity lymphedema patients (10). preventing circulatory constriction. All these facts are particularly important for maintaining dermal Patients with lymphedema have significant volume integrity. Any small lesion in lymphedema patients increases in the foot and ankle making footwear could result in ulceration due to poor circulation, and difficult to find. Due to the swelling of the leg, ankle, decreased healing capacity. Shoe companies have and foot there is restricted range of motion (ROM) stepped up to respond to the need and produced shoes mainly at the ankle joints. These restrictions force that are made specifically for swollen feet and edema. other joints to have to compensate producing pain These models are extra wide, super lightweight, and and altered gait patterns (12). Aggithaya et al (2015) have stretch uppers and a soft toe box. Increased toe while conducting a study of benefits of yoga for spring improves toe off and propulsion. lymphedema analyzed gait deviations of participants. The data showed that the most common gait patterns Lymphedema patients have serious challenges not seen in patients with lower extremity lymphedema the least of which are a lack of availability of medical was antalgia. Due to the pain patients have shorter professionals who specialize the disease, CDT stride lengths and a shorter stance phase which therapists who don’t treat lower extremity disease, ultimately produces an apropulsive waddling gait limited access to appropriate footwear, and insurance (12,13). These risks, as well as the shift in gravity, companies who refuse to cover available treatments. can lead to increased risk falls (12). Gait mapping and Hopefully as more clinicians take an interest in video analyzation of gait patterns can be conducted; lymphedema management patients will have access yet they are time consuming and expensive. But there to the treatments they need to address the disease are easier alternative to this problem. According to early and prevent the severe complications seen with James Dodds, a certified Pedorthist (CPed) at Hanger advanced disease. —PFA Corp. Prosthetics and Orthotics in Philadelphia PA, lymphedema patients benefit from using Oxford style shoes with an open throat Velcro closure system to REFERENCES
accommodate changes in edema. 1. Conrad-Stoppler M, Shiels WC. Lymphedema: Lymphedema Facts. Retrieved from medicinenet.com on Custom or extra depth shoes constructed with Lycra 3/20/2018. fabric stretches and contracts as needed during the 2. Konecne SM, Perdomo M. Lymphedema In The Elderly: different phases of gait. During stance, the throat is A Special Needs Population. Geriatric Rehabilitation. 2004; 20(2): 98-113. closed over the mid-step and held securely by the 3. Goss JA, Maclellan RA, Beijnen UEA, Greene AK. Velcro and stretched Lycra. During swing, the Lycra Resolution Of Primary Lymphedema: A Case Report. Plast contracts and holds the shoe securely on the foot. Reconstr Surg Glob Open. 2017; 5(2): e1223.
50 Pedorthic Footcare Association | www.pedorthics.org 4. King MJ, DiFalco EG. Addressing The Pain: Lymphedema: Oncol. 2018. doi: 10.1002/jso.25033. [Epub ahead of print] Skin And Wound Care In An Aging Population. Ostomy PubMed PMID: 29518822. Wound Management. 2004; 50(5). 10. Weiss J, Spray BJ. The Effect Of Complete Decongestive 5. Do JH, Choi KH, Ahn JS, Jeon JY. Effects Of A Complex Therapy On The Quality of Life Of Patients With Peripheral Rehabilitation Program On Edema Status, Physical Function, Lymphedema. Lymphology. 2002; 35(2): 46-58. And Quality Of Life In Lower-Limb Lymphedema After Gynecological Cancer Surgery. Gynecol Oncol. 2017; 11. Partsch H. Commentary On ‘Haemodynamic 147(2):450-455. Performance Of Low Strength Below Knee Graduated Elastic Compression Stockings In Health, Venous Disease, and 6. McCusker F. Lymphedema Therapy For A Patient With Lymphedema’. Eur J Vasc Endovasc Surg. 2016; 52(1): 113. Obesity And Venous Insufficiency. Lymph Link. 2015: 28(3). 12. Noble-Jones R, Rowley L, Rowley C. Wider Collaboration 7. Farrow W. Phlebolymphedema-A Common on Lymphedema Research Is Needed: Footwear And Gait Underdiagnosed And Undertreated Problem In The Wound Patterns. Journal of Lymphoedema. 2016; 11(1). Care Clinic. J Am Col Certif Wound Spec. 2010; 2(1): 14-23. 13. Aggithaya MG, Narahari SR, Ryan TJ. Yoga For Correction 8. Pappalardo M, Patel K, Cheng MH. Vascularized Lymph Of Lymphedema’s Impairment Of Gait As An Adjunct To Node Transfer For Treatment Of Extremity Lymphedema: An Lymphatic Drainage: A Pilot Observational Study. Int J Yoga. Overview Of Current Controversies Regarding Donor Sites, 2015; 8(1): 54-61. Recipient Sites And Outcomes. J Surg Oncol. 2018. doi: 10.1002/jso.25034. [Epub ahead of print] Review. PubMed PMID: 29572824.
9. Kenworthy EO, Nelson JA, Verma R, Mbabuike J, Mehrara BJ, Dayan JH. Double Vascularized Omentum Lymphatic Transplant (VOLT) For The Treatment Of Lymphedema. J Surg
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Did you know pedorthic and health care certification/accreditation organizations practitioners, who submit an article or that recognize publication as a means to research abstract/research paper, are earn your certification credits.* eligible to earn one or more CEU Credits ? towards keeping their professional For more details, contact Current certification current when accepted and Pedorthics magazine at (229) 389-3440 published in our magazine? or by email at: [email protected] for additional The Pedorthic Footcare Association (PFA) upcoming special interest topics, offers our members and other affiliated guidelines and other ideas you may want to health care professionals an additional discuss as topic ideas beneficial to health way to earn their mandatory Continuing care, patient care and all areas of interest Education Units/Continuing Education in the pedorthics practice and other Points. After successful publication of associated industries. your submitted article or abstract/research ? paper, our staff or you can report your *Credit value is determined by the publication to many of the numerous certification/accreditation organization, not professional health associations and PFA.
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Current Pedorthics | November/December 2018 53 PRODUCTS&SERVICES
This reference guide is intended solely to make it easier our readers, Current Pedorthics has noted the year the company for individuals, facilities and companies to locate pedorthic joined PFA in parentheses after the company’s name. Inclusion products. Companies listed in the guide are PFA vendor/ in this list does not suggest or imply PFA endorsement of manufacturer members. Companies may produce additional companies or products. Vendor/Manufacturer members are products beyond those listed, and most companies are pleased encouraged to keep their listing up-to-date. To arrange changes to provide additional information on request. As a courtesy to in your company’s listing, email: [email protected].
of Akaishi products is able to Wheaton, IL afford wearers with unsurpassed Arizona AFO, Inc. (2003) Phone: (800) 235-8458 comfort and support. Following Arizona AFO manufacturers a Fax: (630) 653-5077 Acor (1979) overwhelming success in Japan, line of medical ankle braces for Email: [email protected] Custom Inserts, AFO Gauntlets, AKAISHI aims to bring comfort the treatment of foot disorders. Website: www.bintzco.com Materials, Accessories and and health to the feet of women The Arizona AFO line is used by Supplies. Originator of Tri-Lam, throughout the world. physicians and practitioners as P-Cell and Microcel Puff. a way to increase mobility, avoid Gardena, CA pain, avoid surgery and provide a Cleveland, OH E-mail: kurato.sato@akaishiusa. better quality of life. Phone: (800) 237-2267 com Fax: (216) 662-4547 Mesa, AZ Website: www.akaishiusa.com Phone: (480) 222-1580 Birkenstock USA, LP (1990) Email: [email protected] U.S. distributor of Birkenstock Website: www.acor.com Fax: (480) 461-5187 Email: [email protected] sandals, shoes, clogs and arch Website: www.arizonaafo.com supports, and also representing Footprints shoes and Birko Orthopadie arch supports. Novato, CA Amfit Inc. (1996) Phone: (800) 949-7301 Since 1977, Amfit has elevated Fax: (415) 884-3250 Aetrex Worldwide, Inc. (1973) custom foot orthotics in the Bestsole, Inc. (2010) Email: [email protected] Aetrex Worldwide has been a computer age. From diabetic Website: www.birkenstockusa. supplier of footcare products for care to professional athletes We manufacture and distribute com 60 years. Aetrex’s brands include and beyond – Amfit 3D contact a glycerine-filled, therapeutic, Aetrex® and Apex Footwear, technology offers innovative, massaging insole. Our insoles Lynco® Orthotics, iStep® and raw user-friendly tools to create the will massage your feet and materials. exact results you desire. From increase circulation to your feet. small scale operations to large They are also excellent shock Teaneck, NJ labs. Where technology fits. absorbers for your feet, knees, Brooks Sports, Inc. (2001) Phone: (800) 526-2739 Perfectly. Amfit is your custom hips and back. One pair fits in all Brooks Sports, Inc., is proud of Fax: (201) 833-1485 foot orthotic partner. shoes. Our insoles are machine our hard-earned reputation for Email: [email protected] washable. We offer a two-year Vancouver, WA engineering footwear that provides Website: www.aetrex.com replacement warranty. Our Phone: (800) 356-3668 the perfect ride for every stride. insoles have always been made Fax: (360) 566-1380 Brooks works to ensure that all of in the USA. Visit our website for Email: [email protected] our footwear products meet the additional products. Affinity Insurance Services, Website: www.amfit.com biomechanical needs of runners, Inc. (1998) enhance comfort, and aid in the Boynton Beach, FL Affinity Insurance Services prevention of running-related Phone: (866) 301-3338 administers the PFA product injury. We’re dedicated to reducing Fax: (561) 547-4684 and malpractice liability running injury risk and have aligned Email: [email protected] insurance program. Designed for ourselves with some of the top Website: www.massaginginsoles. pedorthists, insurance protection researchers around the work to Apis Footwear Company com can be customized for each‑PFA (2000) tackle this. member. Mt. Emry therapeutic line - Bothell, WA Chicago, IL accommodate, never correct! We Phone: (800) 2-BROOKS Phone: (800) 544-2672 have the shoes to accommodate Fax: (425) 483-8181 Fax: (312) 922-9321 charcot, edema, hammer toes, com Email: [email protected] bunions & RA. Whether for depth, Website: www.brooksrunning.com width or even for shape, select Akaishi (2013) from our variety of styles to fit that special foot of your patient. Akaishi strives to provide an unfailing level of comfort and Bintz Company, Inc. (1991) S. El Monte, CA satisfaction to each customer. Phone: 626-448-8905 Distributor of pre-molded After years of research into the orthotics, comfort foot products, Fax: 626-448-8783 Bunion Bootie (2014) structure of women’s feet and E-mail: [email protected] fitting aids and sheet goods. legs, AKAISHI has discovered Products from Birkenstock, Birko Web site: www.bignwideshoes. Say good-bye to painful rigid the key to long term foot care com Orthopadie, Pedag, Powerstep, and health. Through rigorous Spenco, Pedifix, Knit-Rite, Hapad, splints, pads that do not stay functional testing, each line Rieckens PQ and more. in place, and spacers that are
54 Pedorthic Footcare Association | www.pedorthics.org PRODUCTS&SERVICES
difficult to walk in. Bunion Bootie footbeds. Hand-crafted in is the complete bunion treatment Germany. Goodhew, LLC (2012) Honeywell Safety Products Goodhew, a leader in the (2013) package; protective, supportive, Thousand Oaks, CA ModernCraft movement, NEOS overshoes provide a comfortable, and not to mention, Phone: (805) 375-0038 tough barrier between everyday discreet. Truly one-of-a-kind in Fax: (805) 375-0848 spins fresh designs, natural the world of bunion treatments. performance yarns, and footwear and the harsh elements Email: [email protected] of nature. Wear over your favorite, The newest in bunion treatment Website: www.finncomfort.com the heritage of American to help manage your bunion pain craftsmanship to create high comfortable shoes or boots and best of all - it doesn’t involve performance socks for the with confidence that feet and surgery! everyday world. Goodhew: a sock footwear will stay warm and dry. Foot Solutions (2012) for every walk in the walk of life. NEOS are extremely lightweight San Luis Obispo, CA Feet are your foundation and easy to get on and off. With different heights, insulation and Phone: (877) 208-4540 for life. At Foot Solutions, Chattanooga, TN traction to offer the right amount Email: [email protected] we use the most advanced Phone: 423-643-0821 Website: www.BunionBootie.com technology combined with a full of protection, NEOS has you Fax: 423-643-0825 covered. understanding of biomechanics E-mail: eeckardt@goodhew. of feet and gait, along with the us.com Smithfield, RI C.N. Waterhouse Leather Co., highest quality footwear on Web site: www.goodhew.us.com Phone: (401) 757-2503 Inc. (1998) the planet to fit your unique feet. Through our customized Fax: (401) 233-7641 Manufacturer and distributor of E-mail: jennifer.stritzinger@ fine leathers, woolskins, suede solutions, we will improve your comfort and body alignment and Guard Industries, Inc. (1996) honeywell.com pig-skins, sheet goods and Website: www.overshoe.com adhesives for use in the pedorthic help you achieve better health Components for shoe care, footwear and orthopedic through your feet. foot comfort, orthotics and industries. prosthetics. Complete listing of Marietta, GA available products will be sent Hyannis, MA Phone: (888) FIT-FOOT upon request. Fax: (770) 953-6270 Phone: (800) 322-1177 St. Louis, MO Fax: (508) 771-2300 Website: www.footsolutions.com Phone: (800) 535-3508 ING Source, Inc. (2013) E-mail: info@waterhouseleather. Fax: (314) 534-0035 com ING Source, Inc. is a consumer Email: [email protected] Website: www. health and medical device Frankford Leather Company, Website: www.guardmfg.com waterhouseleather.com Inc. (1997) manufacturer selling products Frankford Leather Co., Inc., is world-wide. Our origins were in your single source supplier for design, development, sourcing Dr. Comfort (2004) your pedorthic shoe repair and Haflinger/Highlander and marketing consulting. ING (Gerda Hoehm) (1999) Source holds several patents, and Dr. Comfort manufactures, shoe store supply needs. In stock, more than 8,000 products Boiled wool slippers, latex is the creator of the innovative warehouses and distributes the OrthoSleeve Branded products finest quality extra-depth shoes are available for immediate arch support, felt and leather shipment. Representing major clogs, cork molded footbed. of FS6 Compression Foot Sleeve; for diabetics or patients who CS6 Compression Calf Sleeve; brands and lines like Vibram, Highlander is Gerda Hoehm’s need quality comfort shoes. KS6 Patella Knee Sleeve; ES6 Soletech, Spenco, Powerstep, new high-quality comfort line Mequon, WI Compression Elbow Sleeve; and Pedifix, Pedors, Orthofeet, with a removable footbed. Both Phone: (800) 992-3580 the DermaSox Foot Treatment Kiwi; shoe care, adhesives, Fax: (262) 242-9300 Haflinger and Highlander are System. ING Source also offers leather and more. Free catalog Email: [email protected] made in Germany. OEM for compression wear and available. Website: www.drcomfort.com New York, NY orthopedic support in sports, Bensalem, PA Phone: (212) 949-6767 rehabilitation and Diabetic Foot Phone: (800) 245-5555 Fax: (212) 949-8833 Care to numerous premium Fax: (215) 244-4411 Drew Shoe Corporation Email: [email protected]. brands. Email: sales@frankfordleather. (1968) net com Hickory, NC Men’s and women’s depth Website: www.frankfordleather. Phone: (828) 855-0481 and comfort footwear in over com Fax: (877) 635-1521 150 sizes. Hapad, Inc. (1988) E-mail: [email protected] Lancaster, OH Hapad is a leading manufacturer Website: www.ingsource.com Phone: (800) 837-3739 Gadean Footwear (2010) of 100% natural wool felt foot Fax: 740-654-4979 products and sports replacement Gadean Footwear is the largest Email: customerservice@ insoles used for conservative orthopaedic shoemaker in J.H. Cook & Sons, Inc. drewshoe.com management of common, painful Australia. Gadean Footwear (2004) Website: www.drewshoe.com foot complaints. Correctly skived provides retailers with washable Shoe modification components, and adhesive backed for a quick slippers, motion shoes, fashion foot comfort products and shoe and easy fit, Hapad products shoes, depth shoes, removable repair supplies. Products from insole sandals and many more are an affordable alternative to Aetrex, Spenco, Vibram and products. custom made devices or they Soletech. can be used to make custom Malaga, Western Australia, modifications. Granite Quarry, NC Australia Phone: (704) 279-5568 Finn Comfort (1993) Phone: 61-8-92486533 Bethel Park, PA Fax: (704) 279-5261 Phone: (800) 544-2723 Luxury comfort footwear. Men’s Fax: 61-8-92486711 Email: [email protected] Fax: (800) 232-9427 and women’s walking shoes, Email: info@gadeanfootwear. Email: [email protected] sandals and boots featuring com.au removable/modifiable orthopedic Website: www.gadeanfootwear. Website: www.hapad.com com.au
Current Pedorthics | November/December 2018 55 PRODUCTS&SERVICES
Canadian manufacturer and FOOTWEAR, was founded For over forty years National distributor of orthopedic and more than 40 years ago by Shoe has taken pride on shoe repair machineries, is Martin Michaeli. Mephisto has providing exceptional service to the undisputed leader and the a loyal following and a strong our customers by offering: Industry’s main supplier for international reputation for • Leading, Reputable and North America and Australia. comfort and quality. Its high- Premium Quality Brands Landis International offers JMS Plastics Supply (1992) quality handcrafted footwear • A Knowledgeable and new and reconditioned quality styles include sandals, boots, JMS is the first U.S. company Professional Sales Team equipment, tools, as well as the clogs, dress and classic walkers, to have Silpure in our nylon top • Unparalleled Customer Service necessary parts required for the as well as the ergonomic brand, cover on our Neolon. Silpure Our relationships are built on a maintenance of equipment built Mobils. In recent years, the is an advanced anti-microbial foundation of trust, respect and a to last a lifetime. company also introduced the protection that provides proven desire to partner in the continued more athletic inspired brand, anti-bacterial properties of silver. 800, Rossiter success of our customers and Allrounder by Mephisto and their Available in 1.5 mm and 3.0 mm Saint-Jean-sur-Richelieu vendors through innovation latest collection with superior sheets. Our Neolon with Bamboo (Québec) Canada J3B 8J1 and continuous improvement. is also deodorizing and anti- Phone: 1-450-359-8800 toning technology, Sano by At National Shoe we offer an bacterial and comes in sheets Toll-free: 1-800-634-0806 Mephisto. extensive material & footwear 40” x 48” or 48” x 80”. Our new Fax: 1-450-359-9619 selection for the Pedorthic/ J-fab line of prefabs are thin, heat Email: [email protected] Franklin, TN Orthopaedic/Prosthetic, Shoe moldable and they come in three Website: http://landisusa.com Phone: 800-775-7852 Store and Repair channels of styles and three colors. Fax: 615-771-5935 business across Canada and the E-mail: [email protected] United States Neptune, NJ Web site: www.mephisto.com Phone: (800) 342-2602 Lord Custom Molded Shoes, Inc. (1994) Fax: (732) 918-1131 Toronto, ON E-mail: [email protected] Fashionable custom-molded Phone: 800-387-5246 Miami Leather Company Website: www.jmsplastics.com shoes for men, women, and Fax: 800-568-8930 (2001) children. Guaranteed fit and Websites: www.nationalshoe.com service. Wholesaler to the orthopedic, www.biotimefootwear.com Bohemia, NY prosthetic, retail shoe and shoe Phone: (800) SHOES11 repair trades. Wide variety of Justin Blair & Company Fax: (516) 471-3090 products. (2001) Website: www.lordshoes.com Miami, FL Manufacturer of Ralyn Shoe Care Phone: (305) 266-8328 and Backroom Supplies and Fax: (305) 266-8728 NightCare Foot Care. Distributor Email: [email protected] New Balance (1990) for Aetrex, Acor, Darco, Herbal Website: www.miamileather.com New Balance, headquartered in Concepts, Pedifix, Swede-O, Boston, MA supports a family of Silipos and Therafirm. brands including New Balance, Chicago, IL mediUSA, LP (2013) Aravon, Dunham, PF Flyer, Phone: (800) 566-0664 Warrior and Brine. All brands Fax: (773) 523-3639 Our company slogan “medi. I feel better.” reflects our view specialize in sizes and widths Email: [email protected] across a number of categories Website: www.justinblairco.com of ourselves as a partner to everyone who operates in the including running, walking, medical aids market training, kids, comfort casual, With our products and lifestyle, team sports and apparel. technologies, we would like to Boston, MA make people’s lives easier, better Phone: (617) 783-4000 and more comfortable. We aim to Nolaro24, LLC (2015) Fax: (617) 783-7050 do this by meeting the different Nolaro24, LLC is the Maker of Website: www.newbalance.com needs of all our customers, every Quadrastep and littleSTEPS foot KLM Laboratories (2006) day and throughout the world. orthotics - the first Patented An industry leader in the “I feel better” is therefore a custom to foot type prefabricated new manufacture of foot orthotics promise that becomes a reality foot orthotics for adults and kids, and insoles, specializing in with medi, because we offer the Next best thing to Custom! custom orthotics, pre-fabricated indication-specific and effective step orthotics, orthotic insoles and product solutions to the highest 80 Turnpike Drive, Unit 2B orthortic lab, inc. orthotic materials. standards, which, with the help Middlebury, CT 06762 Valencia, CA of our pioneering, individual Phone (Toll Free): (877) 792-4669 New Step Orthotics (2015) Phone: (800) 556-3668 concepts and dense customer Website: www. At New Step Orthotics our Fax: (800) 556-3338 service network, can be provided thequadrastepsystem.com mission is to provide quality Email: [email protected] wherever they are needed. Email: info@ orthotics and services that Website: www.klmlabs.com thequadrastepsystem.com reflect our effort to a quality Whitsett, NC product with excellent customer Phone: (800) 633-6334 service. We offer a 7 day in house Fax: (888) 570-4554 turnaround on all custom foot E-mail: [email protected] orthotics. We offer free in-bound Web site: www.mediusa.com shipping to our customers and a 1 year product warranty. Family owned since 2004. Mephisto (1998) National Shoe Specialties & Landis International (2014) With worldwide headquarters in Biotime Footwear (2014) Phone: 866-798-7463 Website: www.newsteporthotics. Landis International Inc., a Sarrebourg, France, MEPHISTO National Shoe Specialties & - the WORLD’S FINEST Biotime Footwear (2014) com
56 Pedorthic Footcare Association | www.pedorthics.org PRODUCTS&SERVICES
orthotics, secure closure and relief and prevention of any new STS Company (1997) maximum customization. pains or deformities. Medical Resin-impregnated tubular and practitioners must first be Kent, WA fitted socks made to take foot certified to order from us because Phone: (800) 877-6738 and ankle impressions for custom we offer a completely different Fax: (800) 597-8668 shoes and foot/ankle orthotic type of support than the ones for PartnerShip (2000) Email: customerservice@ devices. which they were trained in school The PFA Shipping Program, propetusa.com Mill Valley, CA and because we must have the managed by PartnerShip, features Website: www.propetusa.com Phone: (800) 787-9097 best possible cast of your foot to discounted shipping rates with Fax: (415) 381-4610 make the best support. FedEx®, UPS Freight® and YRC. Email: [email protected] PFA members can enroll in this Lyles, TN Website: www.stssox.com free member benefit and take P.W. Minor, Inc. (1968) Phone: 931-670-6111 advantage of savings on every P.W. Minor is the premium brand Fax: 931-670-6008 E-mail: [email protected] shipment – inbound, outbound, that provides pedorthically Website: www.solesupports.com business to business, business superior, precision-fit footwear to consumer, express, small for discriminating consumers package ground, tradeshow and unwilling to compromise style LTL freight - all with no shipping when preventing or caring Spenco Medical Corporation minimums or requirements. (2013) For more information or to for their foot-health needs. Shoe Systems Plus, Inc. Delivering foot-health through (2003) Spenco is an innovative enroll today please visit www. healthcare company whose precision fit shoes is a brand Complete line of orthotic and partnership.com/57PFA, call mission is to help people mission that remains as true and prosthetic equipment including 800-599-2902 or email sales@ everywhere achieve more finishers/grinders, vacuum pans, partnership.com. relevant today as it was back in comfortably. While Spenco’s pumps, presses, industrial sewing Cleveland, OH 1867. core business revolves around machines, fume busters and Phone: (800) 599-2902 producing high quality insole more. Fax: (800) 439-8913 Batavia, NY and footcare products, Website: www.partnership.com Phone: (800) 796-4667 Goshen, NY Spenco also provides the most Fax: (585) 343-1514 Phone: (800) 354-6278 advanced sports medicine E-mail: [email protected] Fax: (845) 291-7097 and first aid products. Above Website: www.pwminor.com Email: shoesystemsplus@hvc. all else, customer service is rr.com Spenco’s focus and we are Website: www.shoesystemsplus. 100% committed to providing com outstanding service as we help PediFix, Inc. (2001) Remington Products (2000) you find the solutions for all of Foot specialists since 1885, Insoles and sheet packages, rigid your health and footcare needs. PediFix is the only fourth arch supports, viscoelastic heel generation, family-owned cups, 3/4 and full insoles. Waco, TX business in the pedorthic Phone: (800) 877-3626 industry. Choose from more Wadsworth, OH SoleTech, Inc. (1994) E-Mail: [email protected] than 150 quality foot treatment Phone: (330) 335-1571 SoleTech Inc., established in Website: www.spenco.com products, including a unique OTC Fax: (330) 336-9462 1946, has a full line of cushioning line guaranteed to generate cash Email: [email protected] and fabrication materials for sales, keystone profits and doctor Website: www.remprod.com the pedorthic footcare industry. referrals, an assortment of both Soletech introduced its registered traditional and exclusive Visco- brand Cloud EVA and Soleflex GEL foot pads and cushions, new EVA in the early 1980s and is now dermatology products, GelStep Renia GmbH (2001) recognized as the industry leader Spira (2004) silicone insoles and orthotics, Specially designed adhesives for materials for the fabrication of El Paso, TX Diabetic Solutions Socks, and components for the shoe custom foot orthotics and AFOs Phone: (866) 838-8640 PediPlast and more. 15 new industry, shoe repair trade, and O and components for build-ups Fax: (915) 838-8641 products are being introduced & P industry. and modifications to extra-depth Website: http://spira.com this year. and custom footwear. In addition Cologne, Germany Contact PediFix today for a free to its presence in the orthopedic Phone: 49-221-6307990 color catalog. market, SoleTech is also a leading Streifeneder USA (1997) Fax: 49-221-63079950 supplier of footwear components Brewster, NY Preformed insoles, diabetic Email: [email protected] and materials to the shoe Phone: (800) 424-5561 shoes and materials in different Website: www.renia.com manufacturing and shoe repair Fax: (845) 277-2851 hardnesses, especially for industries. Email: [email protected] diabetics. Website: www.pedifix.com Claremont, NH Tampa, FL Phone: 603-542-8905 Phone: (800) 378-2480 Toll Free: 877-625-9494 Fax: (813) 246-5998 Fax: 603-542-8909 E-mail: [email protected] Email: [email protected] Website: www.eurointl.com Website: www.soletech.com SAS Shoemakers (1992) Propet USA, Inc. (2000) Comfort walking shoes for Leading manufacturer in men’s women and men in a wide range Sole Supports, Inc. (2012) and women’s comfort walking of widths and sizes. shoes. Available in up to 5 widths, Sole Supports is an innovative, San Antonio, TX sizes 5-13 in women’s, 7-17 in medical-grade foot orthotics Superfeet Worldwide LLP men’s. Propet features a vast Phone: (210) 924-6561 manufacturer. We make custom (2003) selection of Medicare A5500 Fax: (210) 921-7460 foot supports that follow your Ferndale, WA coded footwear with removable Email: [email protected] doctor’s prescription in order Phone: (360) 384-1820 Website: www.SASshoes.com to provide both immediate pain
Current Pedorthics | November/December 2018 57 PRODUCTS&SERVICES
Fax: (360) 384-2724 line of contemporary, fully the last rubber soling plants in the Email: [email protected] accommodating custom-molded USA - the Quabaug Corporation in Website: www.superfeet.com shoes, including the Thera-Medic North Brookfield, MA. Shoe package – the most flexible, highest value shoe package for Concord, MA TechMed 3D (2011) Medicare-eligible patients with Phone: (978) 318-000, ext. 136 diabetes. E-mail: [email protected] TechMed 3D is an easy to use, UniStyle Footwear (2017) accurate, and portable solution Buffalo, NY Website: http://us.vibram.com/ for the digital acquisition of Phone: (800) 843-6653 Since 2003, UniStyle Footwear images and measurements Fax: (716) 881-0406 has been manufacturing of human body parts, giving Email: [email protected] fashionable comfort, orthopedic orthotists, prosthetists and Website: www.trumold.com and custom footwear. UniStyle pedorthists access to very reliable Footwear provides quality handcrafted footwear according Ziera Shoes N.Z., Ltd. and consistent measurements. (Formerly Kumfs Shoes N.Z., Tru-Mold Shoes, Inc. (1980) to rigorous quality standards and Levis, Quebec, Canada use the best natural materials, Ltd.) (1998) Tru-Mold Shoes offers a complete Phone: (418) 836-8100 quality leathers, and breathable Ziera Shoes, formerly Kumfs line of contemporary, fully Fax: (418) 836-1589 lining. Shoes, are women’s shoes, Email: [email protected] accommodating custom-molded sandals and boots that are truly Website: www.techmed3d.com shoes, including the Thera-Medic North York, ON M3J 2R8 Shoe package – the most flexible, Phone: (416) 638-7000 orthotic friendly. Ziera Shoes highest value shoe package for Fax: (416) 638-7627 come in a wide range of heeled Medicare-eligible patients with Email: [email protected] fashion and walking footwear. diabetes. Website: www.unistyleshoes.ca We have widths in stock from M through XXW in sizes 34 through Buffalo, NY 45. Therafirm (A Division of Phone: (800) 843-6653 Value Foam, Inc. (2014) Fax: (716) 881-0406 Knit-Rite, Inc.) (1999) Value Foam Inc. is devoted to Email: [email protected] Port Orchard, WA. Quality medical-grade offering our customers high Phone: 877 717 0588 compression hosiery and diabetic Website: www.trumold.com quality, low cost materials Fax: 877 717 0589 socks. commonly used for orthotic and Email: craig.taylor@zierashoes. prosthetic devices. Bring us your Ellerbe, NC Trufit Orthopedic Labs com current invoice, we will be happy Phone: (800) 562-2701 (2013) Website: www.zierashoes.com Fax: (910) 652-2438 to offer you the same type of Website: www.therafirm.com Trufit Biomechanics Labs is a materials at 10 percent less. Our full service biomechanics and product lines include high quality podiatric company. We manufacture EVA, AccuZote (a more economic individually engineered CAD/CAM substitute of plastazore) and PPT/ Tekscan, Inc. (1994) corrective foot orthotics in the USA. SBR materials at various density Broad range of pressure We operate multiple chiropractic and and thickness. assessment and clinical/research podiatric patient-care facilities across evaluation tools for use in Europe. In addition to operating South El Monte, CA orthotics, brace evaluations, joint several patient clinics in Europe, Phone: (800) 788-1358 biomechanics, and gait analysis. we continuously engage in highly Fax: (800) 788-1358 Boston, MA funded research and development E-mail: [email protected] Phone: (617) 464-4500 projects in conjunction with several Web site: www.valuefoams.com Fax: (617) 464-4266 European government laboratories Email: [email protected] as joint ventures that have become Website: www.tekscan.com very successful in developing new patient care evaluation techniques and innovative medical corrective Thor-Lo, Inc. (2001) devices, grounded in science. Statesville, NC Our commitment to Research, Phone: (704) 872-6522 Development and Innovation is a Vibram USA (1998) Fax: (704) 838-6323 foremost goal, and we only employ Since 1937, Vibram has stayed true Website: www.thorlo.com medical, engineering, and computer to its heritage by building products science professionals who share that focused on quality and performance vision. while keeping the end user in mind. Each sole, heel or rubber component Orlando, FL is built with proprietary compounds Phone: 855-910-2525 and endless quality control. We are Treadlabs (2017) Fax: 321-202-2819 also proud to say that we produce Tru-Mold Shoes offers a complete E-mail: [email protected] millions of soles each year in one of Website: www.trufitusa.com
58 Pedorthic Footcare Association | www.pedorthics.org ADVERTISERINDEX
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The advertiser index is published for the readers’ convenience. Click on the hyperlink to take you to the advertiser's website. If you have any questions about advertising, please contact our advertising sales representative:
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ABC (American Board for Certification in Orthotics, ICF abcop.org Prosthetics and Pedorthics, Inc.)
Acor pg. 23 acor.com
Amfit pg. 3 amfit.com
Apis pg. 13 apisfootwear.com
Apex pg. 33 apexfoot.com
Bintz Company pg. 7 bintzco.com
CuraFoot3D pg. 43 curafoot3d.com
DJO / Dr. Comfort pg. 48 drcomfort.com
JMS pg. 4 jmsplastics.com
Kiwi pg. 40 kiwiorthoticservices.com
New Balance pg. 11 newbalance.com
New Step pg. 51 newsteporthotics.com
OS1st pg. 39 os1st.com
Revere pg. 22 revereshoes.com
Spira pg. 10 spira.com
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