A patient came in to pick up her orthotic devices this morning. She has worn orthotics for years for several pathologies but what we were addressing primarily today was pain secondary to digital contracture. She is starting to get more pain at the distal aspect of her toes secondary to hammertoes and pressure on the distal aspect of the digits. In the past, she has found that shoes that have a crest in them tend to work well for her. In particular, she has found that the crest in Birkenstock sandals help keep her toes straight and decrease her symptoms. Because that has been effective, we wanted to add a crest pad to her orthotic devices.

If you are going to try and add a crest pad to orthotics, it is critical that it be placed in the right position. For this reason, I do not think that this is something that the laboratory should add to the orthotics. It is just too subjective as to where the patients like these crest pads to be placed to have that lab add them.

The patient arrived today to pick up her new orthoses, which are polypropylene with a full-length cover along with a layer of Poron glued to the bottom of the EVA cover. The orthoses themselves appeared to fit very well. In order to place the crest pad in the correct position, I took the patient to the ortho-poser and had her stand on it. I then placed lipstick on the distal aspect of each of toe and each metatarsal head. I then placed her directly down on the orthotics, so that the lipstick would transfer and indicate where the toes and metatarsal heads were. Obviously, the sulcus would lie between these two areas. After that, I placed a piece of white paper down over the top of the orthoses, so that mark would transfer the paper. I then cut a template out of the paper and then used that to trim a piece of 3 mm sticky felt to the shape of the crest that I wanted. I then placed this on the bottom of the orthotic top cover.

I am going to let her wear this for couple of weeks and then return to clinic. It is fairly subjective how high it should be to make her most comfortable so we will add or subtract from this temporary crest pad until she is as comfortable as we can possibly get her. At that point, I will remove the felt and make one out of Korex. I will glue that to the bottom of the cover and then place a Vinyl bottom cover on the orthoses.

This is an uncommon modification but it is a useful one for some patients. Again, my biggest piece of advice for making this type of modification is to do it in the office and not order from the lab. It is just very difficult to have a crest pad added that is