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Author: Larry Huppin, DPM Created: 8/6/2009 8:04 AM
Discussion of orthotic therapy for specific patients

By Larry Huppin, DPM on 3/5/2012 11:09 AM
   I did a consult with a ProLab client yesterday regarding a patient who was laterally unstable and how best to write the orthotic prescription. He stated that in the biomechanical exam he measured the resting calcaneal stance position as nearly 10 degrees inverted. I then asked if he had performed the Coleman block test to determine whether it was the forefoot that was holding the foot inverted, or if this patient had a rigid inverted rearfoot. He had not checked that and did not know the answer. This is a critical question when looking at a patient who has an inverted heel, so he decided to have the patient return to clinic so that he could perform the Coleman block test.

The Coleman block test consists of supporting the lateral forefoot in order to determine if
By Larry Huppin, DPM on 2/16/2012 11:21 AM
 I had a patient present today with a complaint of a two-year history of digital numbness and tingling during activity. This was occurring on the right side only. It tended to get worse with increased activity such as hiking and running. He also found that shoes that had a lower heel height differential tended to decrease his symptoms. He had tried a number of over-the-counter arch supports and shoes without any significant improvement of his symptoms.

Read more for orthotic recomendations....
By Larry Huppin, DPM on 1/12/2012 9:29 AM
I consulted with a ProLab client today regarding a patient with pain at the calcaneal cuboid joint. He apparently has a fairly stable foot with mild eversion of the heel in stance. Pain is achy with activity and there is a little pain to palpation dorsolaterally. Radiographs were negative.

He does not have an exact diagnosis, but if nothing else, he is certainly having some calcaneal cuboid arthralgia. In a way, it doesn’t really matter what the exact diagnosis is. For patients with chronic pain in the area of the calcaneal cuboid joint we have a fairly straightforward goal of treatment, regardless of the underlying etiology. Our goal is to minimize motion of the calcaneal cuboid joint and to transfer pressure from the lateral column to the medial column. 

The following is the prescription that we recommended for this patient:
By Larry Huppin, DPM on 12/1/2011 8:02 AM
 I saw a patient this morning who presented with significant pain affecting the right foot, particularly in the area of the first metatarsophalangeal joint. Fourteen months ago, she had surgery to correct a bunion. It appears that she likely had a head procedure. She developed a nonunion, and then six months ago had a second procedure; a plate was added. She was nonweightbearing for a number of weeks and used a bone stimulator. The nonunion seems to have healed, but she is still having significant pain. She has been using Rocker soled shoes and she did receive a pair of orthotic devices.

She has continued to have significant pain affecting the right foot particularly in the area in the first MPJ and along the first metatarsal shaft.
By Larry Huppin, DPM on 11/10/2011 6:56 AM
A ProLab client called me today with questions regarding a prescription for a pair of orthoses for a patient who recently had an arthrodesis of the first metatarsophalangeal joint on the right foot, and was experiencing first MPJ pain secondary to hallux limitus on the left foot. On the right foot, the patient was experiencing metatarsalgia pain with pain primarily under the second MPJ.

Our goal of treatment is to decrease pressure on the second metatarsal head on the right foot, and on the left foot to enhance motion in the first metatarsophalangeal joint.

The following was our prescription:
By Larry Huppin, DPM on 10/20/2011 7:52 AM
I had a ProLab client call me today with a question regarding orthotics for a patient who has mild to moderate hallux limitus pain while cross-country skiing. In a previous blog, I had written about orthotics for downhill ski boots, and you can read that here. Cross-Country is a significantly different sport, however, primarily because of the need for motion at the metatarsophalangeal joints in some (but not all) boots.

Cross-Country Ski boots can be somewhat narrow in the heel. This means we have to limit the size of the orthotic in the heel. In addition, heel control is not particularly important while cross-country skiing.
By Larry Huppin, DPM on 6/30/2011 7:28 AM
I received a call from a ProLab client this morning with questions regarding how to make an AFO for a patient who had a poor outcome following a spinal surgery. She developed a dropfoot on the left side. This is not an unusual complication of such a surgery. What was unusual, however, was that on the right side she had posterior weakness rather than anterior weakness, and developed a calcaneus type of gait. She has a difficult time plantarflexing her right foot and this results in her walking on her heel on the right side, yet having a typical dropfoot on the left side. Our client decided to use a dorsiflexion-assist functional AFO for the left dropfoot (to prevent plantarflexion), but was not sure what to do for the calcaneus type of gait on the right.
By Larry Huppin, DPM on 11/29/2010 1:01 PM
A client today asked for a recommendation for a patient with sub 1 and 5 rheumatoid nodules.

First, all orthotic practitioners should be aware that there are several good studies supporting the use of orthotic therapy in patients with RA. You can find some of rheumatoid arthritis articles listed here

Our goal when treating patients with painful sub-metatarsal nodules is to transfer pressure off of the involved metatarsal heads – in this case met heads one and five.

Here is our recommendation:
  • Material: Semi-rigid polypropylene. Other materials, such as firm Plastizote would also work. The material simply must be rigid enough to resist deformation in order to effectively transfer force
By Larry Huppin, DPM on 10/14/2010 6:14 AM
A patient presented yesterday with painful 4th and 5th toes on the right foot in the steel toe boots he must wear for work. He had tried a number of brands and always developed rather severe pain by the end of the day. The left foot was fine

He had an interesting foot with considerable splay of the toes. He had a hallux varus right along with adductovarus 4 and 5 with lateral splay of the 5th. The pain was coming from pressure on 4 and 5 both dorsally and laterally.

His boots were a size 14C. We keep a Brannock device in the office and his feet measured as a 14C. If the Brannock could measure width at the toes, however, he probably would be a 14EEE. To relieve his pain he would need more room in the toebox both in depth and width. To get a boot that would not put undue pressure on the toes of his right foot, however, could result in a boot that was too large for the left foot.

By Larry Huppin, DPM on 5/24/2010 5:16 PM
I had a client call with the following question today: 

Do you have any idea of how to successfully treat a sheer varus friction type of callus at the plantar tip of the 4th toe? In theory, a good pair of functional orthoses with a Spenco extension should work. But I have never had good success with this. Any suggestions?

This is a tough keratosis to treat with orthoses, but here are a couple ideas. The following information assumes you already have an orthosis that is providing adequate control of the foot.

The most important thing is to use a topcover on your orthosis that will show an impression of areas of increased pressure. For example, Diabetic Topcover works well. This is a tri-layer material with a Poron bottom layer, soft Plastizote middle layer, and a leather topcover. EVA is another material that will show an impression.

After the patie ...
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