Dr. Dujela Handouts

Nail Procedure – Post Operative Instructions 1. Go directly home after the procedure.

2. Do not take aspirin after the procedure. You may take Tylenol is there is discomfort.

3. Leave the bandage on until tomorrow morning. If there is bleeding through the bandage, apply more gauze to the bandage, but do not remove the dressing. Call our office if bleeding seems excessive or cannot be stopped.

4. Tomorrow morning remove the bandage and soak your toe with one of the following options: a. Warm soapy water, OR b. One quart of warm water with 1-2 tablespoons of Epsom salt, OR c. One quart of warm water with 1 tablespoon of Betadine 5. Soak your toe once a day for the next week. Try to keep it clean during the healing period.

6. You can expect some inflammation and drainage for 7-10 days following the procedure, this is normal.

7. You may return to your normal shoes and activities as the toe allows. Say out of public pools and hot tubs until the drainage from the toe stops.

Please call our office at (360)736-2889 if you have any questions or undue discomfort.

1900 Cooks Hill Road, Centralia, WA 98531 (360) 736-2889 1(800)342-0205 FAX (360)736-3136 www.waortho.com

Range of Motion and Stretching Exercises These are some of the initial exercises you may start your rehabilitation program with until you see your physician, physical therapist, or athletic trainer again, or until your symptoms are resolved.

Please remember: • Flexible tissue is more tolerant of the stresses placed on it during activities.

• Each stretch should be held for 20 to 30 seconds.

• A gentle stretching sensation should be felt.

Stretch – Gastrocsleus Note: This exercise can place a lot of stress on your ankle and should only be done after seeing your physician, physical therapist, or athletic trainer.

1. Place your toes and the ball of your foot on a book or the edge of a stair. Your heel should be off of the ground.

2. Hold onto a chair or stair rail for balance.

3. Allow your body weight to stretch your calf.

4. First do this exercise with the knee straight, and then bend the knee slightly.

5. Hold this position for 90 seconds.

6. Repeat exercise 5-10 times, per day.

Stretch – Gastrocsleus 1. Stand one arm length from the wall as shown.

2. Place calf muscle to be stretched behind you as shown.

3. Turn the toes in and the heel out of the leg to be stretched.

4. First do this exercise with the knee straight, and then bend the knee slightly. Keep your hell on the floor at all times.

5. Hold this position for 90 seconds.

6. Repeat exercise 5-10 times, per day.

1900 Cooks Hill Road, Centralia, WA 98531 (360) 736-2889 1(800)342-0205 FAX (360)736-3136 www.waortho.com

Bunions Even though bunions are a common foot deformity, there are misconceptions about them. May people may unnecessarily suffer the pain of bunions for years before seeking treatment.

What is a Bunion?

Bunions are often described as a bump on the side of the big toe. But a bunion is more than that. The visible bump actually reflects changes in the bony framework of the front part of the foot. With a bunion, the big toe leans toward the second toe, rather than pointing straight ahead. This throws the bones out of alignment, producing the bunion’s “bump.”

Bunions are a progressive disorder. They begin with a leaning of the big toe, gradually changing the angle of the bones over the years and slowly producing the characteristic bump, which continues to become increasingly prominent. Usually the symptoms of bunions appear at later stages, although some people never have symptoms.

What Causes a Bunion?

Bunions are most often caused by an inherited faulty mechanical structure of the foot. It is not the bunion itself that is inherited, but certain foot types that make a person prone to developing a bunion.

Although wearing shoes that crowd the toes won’t actually cause bunions in the first place, it sometimes makes the deformity get progressively worse. That means you may experience symptoms sooner.

Symptoms Symptoms occur most often when wearing shoes that crowd the toes such as shoes with a girth toe box or high heels.

This may explain why women are more likely to have symptoms than men. In addition, spending long periods of time on your feet can aggravate the symptoms of bunions.

Symptoms, which occur at the site of the bunion, may include: • Pain or soreness • Inflammation and redness • A burning sensation • Perhaps some numbness Other conditions which may appear with bunions include calluses on the big toe, sores between the toes, ingrown toenail and restricted motion of the toe.

1900 Cooks Hill Road, Centralia, WA 98531 (360) 736-2889 1(800)342-0205 FAX (360)736-3136 www.waortho.com

Diagnosis Bunions are readily apparent; you can see the prominence at the base of the big toe or side of the foot. However, to fully evaluate your condition, Dr. Dujela will take x-rays to determine the degree of the deformity and assess the changes that have occurred.

Because bunions are progressive, they don’t go away and will usually get worse over time. But not all cases are alike.

Some bunions progress more rapidly than others. Once Dr. Dujela has evaluated your particular case, a treatment plan can be developed that is suited to your needs.

Treatment Sometimes observation of the bunion is all that’s needed. A periodic office evaluation and x-ray examination can determine if your bunion deformity is advancing, thereby reducing your chance of irreversible damage to the joint. In many other cases, however, some type of treatment is needed.

Early treatments are aimed at easing the pain of bunions, but they won’t reverse the deformity itself. These options include: • • • • • • •

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

Padding – Pads places over the area of the bunion can help minimize pain. You can get bunion pads from a drug store or supermarket.

Activity modifications – Avoid activity that causes bunion pain, including standing for long periods of time.

Medications – Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may help to relieve pain.

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

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

Orthotic devices – In some cases, custom orthotics or supportive inserts may be of benefit.

When is Surgery Needed?

When the pain of a bunion interferes with daily activities, it’s time to discuss surgical options. There are many different types of bunions and therefore many different types of surgery to fix them as well. You and Dr. Dujela will discuss the option and together you can decide if surgery is best for you.

Recent advances in surgical techniques have led to a very high success rate in treating bunions. A variety of surgical procedures are performed to treat bunions. The procedures are designed to remove the “bump” of bone, correct the changes that may also have occurred. The goal of these corrections is the elimination of pain. In selecting the procedure or combination of procedures for your particular case, Dr. Dujela will take into consideration the extent of your deformity based on the x-ray finds, your age, your activity level and other factors. The length of the recovery period will vary, depending on the procedure or procedures performed.

1900 Cooks Hill Road, Centralia, WA 98531 (360) 736-2889 1(800)342-0205 FAX (360)736-3136 www.waortho.com

Charcot Foot What is Charcot Foot?

Charcot foot is a sudden softening of the bones in the foot that can occur in people who have significant nerve damage (neuropathy). The bones are weakened enough to fracture and with continued walking the foot eventually changes shape. As the disorder progresses, the arch collapses and the foot takes on a convex shape, giving it a rocker-bottom appearance, making it very difficult to walk.

Charcot foot is a very serious condition that can lead to severe deformity, disability and even amputation.

Because of its seriousness, it is important that patients with diabetes- a disease often associated with neuropathy- take preventive measures and seek immediate care if signs or symptoms appear.

Symptoms The symptoms of Charcot foot can appear after a sudden trauma or even a minor repetitive trauma (such as a long walk). A sudden trauma includes such mishaps as dropping something on the foot or a sprain or fracture of the foot. The symptoms of Charcot foot are similar to those of infection. Although Charcot foot and infection are different conditions, both are serious problems requiring medical treatment.

Charcot foot symptoms may include: • Warmth to the touch (the foot feels warmer than the other) • Redness in the foot • Swelling in the area • Pain or soreness What Causes Charcot Foot?

Charcot foot develops as a result of neuropathy, which decreases sensation and the ability to feel temperature, pain or trauma. When neuropathy is severe, there is a total lack of feeling in the feet. Because of neuropathy, the pain of an injury goes unnoticed and the patient continues to walk-making the injury worse.

People with neuropathy (especially those who have had it for a long time) are at a risk for developing Charcot foot. In addition, neuropathic patients with a tight Achilles tendon have been shown to have a tendency to develop Charcot foot.

1900 Cooks Hill Road, Centralia, WA 98531 (360) 736-2889 1(800)342-0205 FAX (360)736-3136 www.waortho.com

Dietary Restrictions - Gout Since gout is caused by high levels of uric acid, with crystals forming in the joints, some dietary measures to reduce purine intake would seem sensible.

Uric acid is a metabolic product of purine nucleic acids. Some purines are made in the body, while other purine comes from the food we eat. Reducing the amount of purines eaten would seem sensible, though evidence to demonstrate that would seem to be lacking. Weight reduction in those who are overweight is probably at least, if not more, important.

Foods with different levels of purines are given in the table below.

Purine Contents of Foods High levels of purines

Moderate levels of purines

Low levels of purines

Best to Avoid

Eat Occasionally

No Restrictions

Liver Kidney Anchovies Sardines Herrings Mussels Bacon Scallops Cod Trout Haddock Veal Venison Turkey Alcohol especially beer

Asparagus Beef Bouillon Chicken Crab Duck Ham Kidney beans Lentils Lima beans Mushrooms Lobster Oysters Pork Shrimp Spinach

Carbonated drinks Coffee Fruits Breads Grains Macaroni Cheese Eggs Milk products Sugar Tomatoes Green vegetables

1900 Cooks Hill Road, Centralia, WA 98531 (360) 736-2889 1(800)342-0205 FAX (360)736-3136 www.waortho.com

Morton’s Neuroma What is a Neuroma?

A neuroma is a thickening of nerve tissue that may develop in various parts of the body. The most common neuroma in the foot is a Morton’s neuroma, which occurs at the base of the third and fourth toes. The thickening, or enlargement, of the nerve that defines a neuroma is the result of compression and irrigation of the nerve. This compression creates swelling of the nerve, eventually leading to permanent nerve damage.

Symptoms of a Morton’s Neuroma • Tingling, burning or numbness • Pain • A feeling that something is inside the ball of the foot or that there’s a rise in the shoe or a sock is bunched up.

Progression of a Morton’s neuroma Often follows this pattern: • The symptoms begin gradually. At first they occur only occasionally, when wearing narrow-toed shoes or performing certain aggravating activities.

• The symptoms may go away temporarily by massaging the foot or by avoiding aggravating shoes or activities.

• Over time the symptoms progressively worsen and may persist for several days or weeks.

• The symptoms become more intense as the neuroma enlarges and the temporary changes in the nerve become permanent.

What Causes a Neuroma?

Anything that causes compression or irritation of the nerve can lead to the development of a neuroma. One of the most common offenders is wearing shoes that have a tapered toe box or high-heeled shoes that cause the toes to be forced into the toe box. People with certain foot deformities-bunions, hammertoes, flatfeet or more flexible feet- are at higher risk for developing a neuroma. Other potential causes are activities that involve repetitive irritation to the ball of the foot, such as running or racquet sports. An injury or other type of trauma to the area may also lead to a neuroma.

1900 Cooks Hill Road, Centralia, WA 98531 (360) 736-2889 1(800)342-0205 FAX (360)736-3136 www.waortho.com

Peroneal Tendon Injuries What are the Peroneal Tendons?

A tendon is a band of tissue that connects a muscle to a bone. In the foot, there are two peroneal tendons. They run side-by-side behind the outer ankle bone. One peroneal tendon attaches to the outer part of the midfoot, while the other tendon runs under the foot and attaches near the inside of the arch. The main functions of the peroneal tendons are to stabilize the foot and ankle and protect them from sprains.

Types of Peroneal Tendon Injuries: Peroneal tendon injuries may be acute (occurring suddenly) or chronic (developing over a period of time). They most commonly occur in individuals who participate in sports that involve repetitive ankle motion. In addition, people with higher arches are at risk for developing peroneal tendon injuries.

Tendonitis is an inflammation of one or both tendons. The inflammation is caused by activities involving repetitive use of the tendon, overuse of the tendon or trauma (such as an ankle sprain). Symptoms of tendonitis include: • Pain • Swelling • Warmth to the touch Acute Tears are caused by repetitive activity or trauma. Immediate symptoms of acute tears include: • Pain • Swelling • Weakness or instability of the foot and ankle As time goes on, these tears may lead to a change in the shape of the foot, in which the arch may become higher.

Degenerative tears (tendonosis) are usually due to overuse and occur over long periods of time-often years. In degenerative tears, the tendon is like taffy that has bene overstretched until it becomes thing and eventually frays.

Having high arches also puts you at risk for developing a degenerative tear. The signs and symptoms of degenerative tears may include: • Sporadic pain (occurring from time to time) on the outside of the ankle • Weakness or instability in the ankle • An increase in the height of the arch

1900 Cooks Hill Road, Centralia, WA 98531 (360) 736-2889 1(800)342-0205 FAX (360)736-3136 www.waortho.com

Subluxation occurs when one or both tendons have slipped out of their normal position. In some cases, subluxation is due to a condition in which a person is born with a variation in the shape of the bone or muscle. In other cases, subluxation occurs following trauma, such as an ankle sprain. Damage or injury to the tissues that stabilize the tendons (retinaculum) can lead to chronic tendon subluxation. The Symptoms of subluxation may include: • A snapping feeling of the tendon around the ankle bone • Sporadic pain behind the outside ankle bone • Ankle instability or weakness Early treatment of a subluxation is critical, since a tendon that continues to sublux (move out of positon) is more likely to tear or rupture. Therefore, if you feel the characteristic snapping, see Dr. Dujela immediately.

Diagnosis Because peroneal tendon injuries are sometimes misdiagnosed and may worsen without proper treatment, prompt evaluation by a foot and ankle surgeon is advised. To diagnose a peroneal tendon injury, Dr. Dujela will examine the foot and look for pain, instability, swelling, warmth and weakness on the outer side of the ankle. In addition, imaging studies such as an MRI may be needed to fully evaluate the injury.

An Ankle sprain may sometimes accompany a peroneal tendon injury. Proper diagnosis is important because prolonged discomfort after a simple sprain may be a sign of additional problems.

Treatment Treatment depends on the type of peroneal tendon injury and include: • Immobilization – A cast or splint may be used to keep the foot and ankle from moving and allow the injury to heal.

• Medications – Oral or injected anti-inflammatory drugs may help relieve the pain and inflammation.

• Physical therapy – Ice, heat or ultrasound therapy may be used to reduce swelling and pain. As symptoms improve, exercise can be added to strengthen the muscles and improve range of motion and balance.

• Bracing – The surgeon may provide a brace to use for a short while or during activities requiring repetitive ankle motion. Bracing may also be an option when a patient is not a candidate for surgery.

• Surgery – In some cases, surgery may be needed to repair the tendon or tendons and perhaps the supporting structures of the foot. Dr. Dujela will discuss the most appropriate procedure for our condition and lifestyle. After surgery, physical therapy is an important part rehabilitation.

1900 Cooks Hill Road, Centralia, WA 98531 (360) 736-2889 1(800)342-0205 FAX (360)736-3136 www.waortho.com

Posterior Tibial Tendon Dysfunction (PTTD) What is PTTD? Posterior tibial tendon dysfunction (PTTD) is an inflammation and/or overstretching of the posterior tibial tendon in the foot.

An important function of the posterior tibial tendon is to help support the arch. But in PTTO, the tendon’s ability to perform that job is impaired, often resulting in a flattening of the foot.

The posterior tibial tendon is a fibrous cord that extends from a muscle in the leg. It descends the leg and runs along the inside of the ankle, down the side of the food, and into the arch. This tendon serves as one of the major supporting structures of the foot and helps the food to function while walking.

PTTD is often called “adult-acquired flatfoot” because it is the most common type of flatfoot developed during adulthood. Although this condition typically occurs in only one foot, some people may develop it in both feet. PTTD is usually progressive, which means it will keep getting worse-especially if it isn’t treated early.

Symptoms of PTTD The symptoms of PTTD may include pain, swelling, a flattening of the arch, and an inward rolling of the ankle. As the condition progresses, the symptoms will change.

For example: • When PTTD initially develops, typically there is pain on the inside of the foot and ankle (along the course of the tendon). In addition, the area may be red, warm and swollen.

• Later, as the arch begins to flatten, there may still be pain on the inside of the foot and ankle. But at this point, the foot and toes begin to turn outward and the ankle rolls inward.

• As PTTD becomes more advanced, the arch flattens even more and the pain often shifts to the outside of the foot, below the ankle. The tendon has deteriorated considerably and arthritis often develops in the foot. In more severe cases, arthritis may also develop in the ankle.

What Causes PTTD? Overuse of the posterior tibial tendon is frequently the cause of PTTD. In fact, the symptoms usually occur after activities that involve the tendon, such as running, walking, hiking, or climbing stairs.

1900 Cooks Hill Road, Centralia, WA 98531 (360) 736-2889 1(800)342-0205 FAX (360)736-3136 www.waortho.com

Treatment: Non-Surgical Approaches Because of the progressive nature of PTTD, it is best to see Dr. Dujela as soon as possible. If treated early enough, your symptoms may resolve without the need for surgery and progression of your condition can be arrested. In contract, untreated PTTD could leave you with an extremely flatfoot, painful arthritis in the foot and ankle, and increasing limitations on walking, running, or other activities.

In many cases of PTTD, treatment can begin with non-surgical approaches that may include: • Orthotic devices or bracing: To give your arch the support it needs, Dr. Dujela may provide you with an ankle stirrup brace or a custom orthotic device that fits into your shoe.

• Immobilization: Sometimes a short-leg cast or boot is worm to immobilize the foot and allow the tendon to heal, or you may need to completely avoid all weight bearing for a while.

• Physical Therapy: Ultrasound therapy and exercises may help rehabilitate the tendon and muscle following immobilization.

• Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation.

• Shoe Modifications: Dr. Dujela may advise you on changes to make with your shoes and may provide special inserts designed to improve arch support.

When is surgery needed?

In cases of PTTO that have progressed substantially or have failed to improve with nonsurgical treatment, surgery may be required. For some advanced cases surgery may be the only option.

Surgical treatment may include repairing the tendon, realigning the bones of the foot, or both.

More severe cases may require fusions of joints to reconstruct the foot and relieve pain. Dr. Dujela will discuss the best approach for your specific case.

1900 Cooks Hill Road, Centralia, WA 98531 (360) 736-2889 1(800)342-0205 FAX (360)736-3136 www.waortho.com

Reflex Sympathetic Dystrophy (RSD) What is RSD? Reflex Sympathetic Dystrophy is a chronic pain disorder involving the sympathetic nervous system. It usually is the result of an injury or trauma, but can also be a complication of surgery, infection, casting or splitting and myocardial infarction (heart attack). The trauma sets off the body’s mechanism for pain recognition, but then the “normal system of pain perception” begins to misfire and an abnormal cycle of intractable pain begins. As RSD progresses, the abnormal pain of the sympathetic nervous system has an effect on other areas of the body and can result in total disability as muscles, bones, skin and the autonomic immune system become involved.

The first indication of RSD is prolonged intractable pain usually more severe than the injury. The symptoms are chronic burning pain in a localized area, intense sensitivity to temperature and light touch and a color change to the skin.

Most physicians agree that there are three stages of RSD, which progress at a different pace in each person.

Initially, there is swelling and redness sin the affected area. Next, the area may become blue and cold, with increased pain and stiffness of ligaments and joints, and Osteoporosis may become evident. Finally, there may be a wasting of affected muscles, contraction of tendons and a definite withering of the affected limb. In all of the stages, severe chronic pain continues to be a major complaint. Depression can accompany the life changes of RSD and psychological therapy may help.

Clinical symptoms of RSD Pain is the first and primary complaint described as extremely severe burning or aching. Swelling and joint tenderness. Edema in the area of pain may be hard or pitted joints may be stiff and hard to initiate movement.

Loss or diminished motor function pain may cause a decrease in movement of the extremities. Decreased mobility can lead to atrophy or wasting of muscles. Changes in skin temperature and color. Skin temperature can change from warm to cool or cold to hot. Skin color may be red, bluish or a mottled appearance and may be shiny or dry. Increased sweating at injured area.

How is RSD Treated?

• Drug Therapy • Nerve Blocks • Physical Therapy • Transcutaneous Electrical Stimulator • Implantable devices: Spinal Cord Stimulator, Drug Delivery Infusion Pump, Sympathectomy

1900 Cooks Hill Road, Centralia, WA 98531 (360) 736-2889 1(800)342-0205 FAX (360)736-3136 www.waortho.com

Achilles Tendon Disorder

What is the Achilles Tendon?

A tendon is a band of tissue that connects a muscle to a bone. The Achilles tendon- the longest tendon in the body- runs down the back of the lower leg and connects the calf muscle to the heel bone. Also called the “heel cord,” the Achilles tendon facilitates walking by helping to raise the heel off of the ground.

Achilles Tendonitits and Achilles Tendonosis Two common disorders that occur in the heel cord are Achilles tendonitis and Achilles tendonosis.

Achilles tendonitis is an inflammation of the Achilles tendon. This inflammation is typically shortlived. Over time the condition usually progresses to a degeneration of the tendon (Achilles tendonosis), in which degeneration involves the site where the Achilles tendon attaches to the heel bone. In rare cases, chronic degeneration with or without pain may result in a complete rupture of the tendon.

Symptoms The symptoms associated with Achilles tendonitis and tendonosis include: • Pain-aching, stiffness, soreness, or tenderness-within the tendon. This may occur anywhere along the tendon’s path, beginning with the narrow area directly above the heel upward to the region just below the calf muscle. Often pain appears upon arising in the morning or after periods of rest, then improves somewhat with motion but later worsens with increased activity.

• Tenderness, or sometimes intense pain, when the sides of the tendon are squeezed. There is less tenderness, however, when pressing directly on the back of the tendon.

• When the disorder progresses to degeneration, the tendon may become enlarged and may develop nodules in the area where the tissue is damaged.

Causes As “overuse” disorders, Achilles tendonitis and tendonosis are usually caused by a sudden increase of a repetitive activity involving the Achilles tendon. Such activity puts too much stress on the tendon; the body is unable to repair the injured tissue. The structure of the tendon is then altered, resulting in continued pain.

1900 Cooks Hill Road, Centralia, WA 98531 (360) 736-2889 1(800)342-0205 FAX (360)736-3136 www.waortho.com

Athletes are at high risk for developing disorders of the Achilles tendon. Achilles tendonitis and tendonosis are also common in individuals whose work puts stress on their ankles and feet, such as laborers, as well as in “weekend warriors” – those who are less conditioned and participate in athletics only on weekends or infrequently.

In addition, people with excessive pronation (flattening of the arch) have a tendency to develop Achilles tendonitis and tendonosis due to the greater demands places on the tendon when walking.

If these individuals wear shoes without adequate stability, their over-pronation could further aggravate the Achilles tendon.

Diagnosis In diagnosing Achilles tendonitis or tendonosis, Dr. Michael Dujela will examine your foot and ankle and evaluate the range of motion and condition of the tendon. The extent of the condition can be further assessed with x-rays, ultrasound or MRI. Treatment Treatment approaches for Achilles tendonitis or tendonosis are selected on the basis of how long the injury has been present and the degree of damage to the tendon.

In the early stage, when there is a sudden (acute) inflammation, one or more of the following options may be recommended: • Immobilization: Immobilization may involve the use of a cast or removable walking boot to reduce forces through the Achilles tendon and promote healing.

• Ice: To reduce swelling due to inflammation, apply a bag of ice over a thin towel to the affected area for 20 minutes of each waking hour. Do not put ice directly against the skin.

• Oral Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs), such as Ibuprofen, may be helpful in reducing the pain and inflammation in the early stage of the condition.

• Physical Therapy: Physical therapy may include strengthening exercise, soft-tissue massage/mobilization, gait and running re-education, stretching and ultrasound therapy.

If non-surgical approaches fail to restore the tendon to its normal condition, surgery may be necessary. Dr. Michael Dujela will discuss the best procedure to repair the tendon.

Prevention To prevent Achilles tendonitis or tendonosis from recurring after surgical or non-surgical treatment, Dr. Michael Dujela may recommend strengthening and stretching of the calf muscles through daily exercise. Wearing proper shoes for the foot type and activity is also important in prevent recurrence of the condition.

1900 Cooks Hill Road, Centralia, WA 98531 (360) 736-2889 1(800)342-0205 FAX (360)736-3136 www.waortho.com

HOW TO WEAR ORTHOTIC DEVICES Basic Instructions and Guidelines Like eyeglasses, orthotics may require some adjustment during the break-in period. Be patient and allow your doctor to provide proper instructions to effect correction of the foot imbalance for which this orthotic device was designed.

It will take approximately one to six weeks for you to become accustomed to wearing your orthotics. During this adjustment period, there may be some discomfort in your foot, leg, or direct irritation to the skin. Contact your doctor immediately if the discomfort continues.

Wear the orthotic devices in comfortable shoes with adequate room. Start with one hour and increase wearing time by one hour each day. Do not be discouraged if your adjustment period seems a little longer than mentioned above.

Tips for Orthotic Wear 1. The orthotics should be worn with stockings during the break-in period to minimize skin irritation.

2. You should feel no sharp edges or ridges. There will be some pressure in the arch area.

3. DO NOT run in your orthotics until they can be worn comfortably in walking activities for a typical day.

4. Discuss with your doctor the different types of shoes with which you may wear the orthotics.

5. If the orthotics “squeak,” use foot powder in your shoes or try rubbing the edge of the orthotic with wax or bar soap.

6. The orthotics may be cleaned with mild soap and lukewarm water. DO NOT USE HOT WATER as it may damage the orthotic.

7. You may experience discomfort in other parts of your body such as knees, hips, or back after several consecutive hours of wear. Should this happen, cut back your break-in time by an hour or two. If the pain persists, call your doctor. These symptoms normally disappear as your function improves.

8. It is not unusual for your heel to slip during the adjustment period. Try other shoes and be certain the orthotics fit well in the shoes.

It is important that you follow your doctor’s specific instructions along with these guidelines.

1900 Cooks Hill Road, Centralia, WA 98531 (360) 736-2889 1(800)342-0205 FAX (360)736-3136 www.waortho.com