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By Larry Huppin, DPM on 8/19/2013 6:53 AM
  I had a patient in my office today with complaint of posterior heel pain, right, when wearing several different pairs of his dress shoes. He had a fairly large retrocalcaneal exostosis on the right calcaneus at the proximal aspect of the posterior calcaneus.

There are obviously a number of ways to address the retrocalcaneal exostosis. Our primary goals are to reduce pressure and reduce friction. Reducing pressure in this area is always a little tough without changing shoes. Although you can attempt to stretch shoes in this area, it is usually not particularly effective.

Friction can be controlled in a couple of different ways.
By Dianne Mitchell on 8/15/2013 3:24 PM
I see a fair number of runners in the office for functional foot orthotics and get the frequent request for lightweight and "not so hard" orthotics . In these cases, I find that the features of the ProAerobic Specialty device are great.

This device includes a polyproplyene shell which is flexible (3mm) and it is back-filled from the ground up to the arch with EVA. It also incorporates an EVA rearfoot post for cushion/shock absorption at heel strike. This is light weight device and it offers dissipation of the stress of high impact activities such as running. My runners are really happy in ProAerobic orthotics.

I often modify the ProAerobic prescription to incorporate a deep heel cup and wide shell for additional support and control. Something to consider ...
By Dianne Mitchell on 8/13/2013 3:08 PM
A rigid flat foot was just molded here in the office. Historically this patient was in a pair of insufficent devices which he continued to have pain with. The goal is pain relief / reduction. Thoughts for the rx writing ...

- capture the arch in as close to subtalar neutral as possible without inverting the patient, as this is a rigid deformity and the patient will not tolerate a device which requires motion he doesn't have.
- order a wide device with a medial flange (you can always make the device narrower in the office at the time of dispensing if it is too wide) this will add a supinatory torque and not allow the patient to maximally pronate over the device
- many of these patients will have prominent navicular tuberosities so I mark them before casting and order sweet spots for added cushion
- order a deep heel cup and, pending available motion in the midtarsal joint, I will add a medial skive of 2-4mm for a additional supinatory torque
By Larry Huppin, DPM on 8/13/2013 6:59 AM
 Last week, we presented a Webinar on how to use friction management in order to better treat calluses, ulcers, and blisters. Significant research is showing that friction is a strong contributing component to the formation of these problems and that by using a friction reducing material on the orthosis in areas at risk, that both treatment and prevention of calluses and ulcers is improved. We demonstrated how the PTFE Patch can accomplish this. 
By Dianne Mitchell on 8/8/2013 2:52 PM
I see a lot of patients with lesser metatarsal head pain in the office. Today a great example of 2nd metatarsalgia came in. This patient is really active in cycling and climbing and constantly loads the forefoot in these activities and wants to continue them. He has tried metatarsal cookies / pads and bars without any success and wants options ... what else can you do?

Well, it is important to note that these above modifications were tried on the flat insole of his shoes, no functional foot orthotics have been attempted. This patient was actually sent to me for functional foot orthotics since he was failing the other items.

First, a well molded foot with a orthotic prescription including "minimal arch fill" might very well in and of itself transfer stress from the ball of the foot into the arch and off of the painful site and be enough for the patient. Other things to consider for the forefoot of the device could be anything from simple Poron or EVA padd ...
By Dianne Mitchell on 8/6/2013 2:44 PM
Saw a child in the office today for functional foot orthotics, who presented with hyper-flexible planus foot and a really prominent navicular tuberosity. This patient has had a history of orthotic irritation at this site. A couple things to think about while casting and writing the order for the devices.
Make sure to cast this flexible flat foot in STJ neutral and plantar flex the 1st metatarsal (for this particular patient, this casting position easily recreated the arch and resulted in a nicely balanced cast.) Next, since the patient told you about navicular irritation, mark the cast in this location and order a sweet spot for cushion and pain relief here. Also make sure to prescribe for cast inversion and a medial skive as needed to take the patient out of maximal pronation. A deep heel cup is necessary with these cast corrections to ensure that the orthotics hang onto the heel. I am ordering a 20mm deep heel cup to do this.
By Larry Huppin, DPM on 8/5/2013 2:32 PM
 It is sometimes difficult to fit orthosis for patients who are required to wear steel-toed shoes at work. The reason for this is simply that the number of available steel-toed shoes is somewhat limited and patients simply cannot find a shoe that is comfortable for them and fits well with a foot orthosis.

An option for these patients is to have them
By Dianne Mitchell on 8/1/2013 2:39 PM
Patient presented today for orthotic molding. Patient has a really prominent fascia band with a single fibroma in the midsubstance of both arches. These are presently non-painful and the patient wants to keep it that way ... What can you to with the orthotic perscription??
Add a plantar fascia groove.

This is easy to add! Before casting the patient, mark the fascia with lip stick or betadine solution (something that will transfer to the plaster easily during casting!) This helps the lab identify the proper location of the fascia for the groove to be located and offloads the facsia beautifully to keep patients pain free!
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