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Author: Dianne Mitchell Created: 5/16/2011 9:38 AM
Orthotic Therapy Blog

By Dianne Mitchell on 11/12/2014 9:21 AM
A patient presents to the office with a painful 1st MTPJ. On exam you discover a functional hallux limitus and sub-hallux base callusing. Orthotic considerations:
a. Goal of the orthotic: increase 1st mtpj rom
b. Plantarflexing the 1st metatarsal will raise the 1st MTPJ axis of rotation and therefore decrease or eliminate the functional limitus finding. So, casting this foot in STJ neutral with the 1st metatarsal plantarflexed is essential.
c. Couple this casting technique with a semi-rigid polypropylene shell that is wide with a deep heel cup and flat rearfoot post with minimal arch fill to allow continued 1st metatarsal plantarflexion and stability.
d. Additionally, medial skiving and / or inverting the device will decrease medial column load and further plantarflex the 1st metatarsal to un-jam the 1st MTPJ
e. Finally, if this isn’t enough, or if you are troubleshooting on another providers pair of functional foot orthotics, consider adding a Revers ...
By Dianne Mitchell on 11/5/2014 9:20 AM
Periodically I will see patients in the office who enjoy their orthotics in their higher volume athletic shoes, but report that their heels pop out of the shoes, or they sit too high and their heels rub the “wrong spot” on the heel counter, in lower volume shoes. What can you do to lower the heel position in the shoe? Using your grinding wheel, remove the rearfoot post and proceed to grind the shell of the orthotic as thin as possible without creating a hole. This drops the heel down in the shoe several millimeters to stop the patient from popping out. Note: you must keep the orthotic in a balanced position and not invert or evert the device during this process!
By Dianne Mitchell on 10/29/2014 9:17 AM
Patient presents to the office with a painful arch on their orthotics. I troubleshoot orthotics in the office daily and during my exam I notice this patient has a very prominent plantar fascia band and there is remnant blistering in this distribution.
When you re-examine the devices, you notice there is not a plantar fascia groove. Can you add one? Sure! First, apply lipstick to this distribution on the patient’s foot and then press the device onto the patient’s foot to transfer the marking to the device. Next, apply 1/8” thick Korex directly to the orthotic shell dorsal surface to raise the entire orthotic surface higher, minus the region of the prominent fascia that is nicely marked for you. Finally, cover the device with a fresh top cover! When the patient is ready for a new pair of devices you can integrate the groove into the poly shell!
By Dianne Mitchell on 10/22/2014 9:16 AM
I had the opportunity to attend and lecture at the Colorado State podiatry meeting a couple weekends ago. It was an excellent assortment of talks with numerous “take home and apply in the office” tools. But my two favorite talks were both presented by Dr Kevin Kirby. The first was “Successful Treatment of Peroneal Muscle / Tendon Disorders and the second a discussion of “Barefoot vs Shod.”
The barefoot talks are always pretty interesting, since we live in an environment where shoes are worn. I have a very small patient population who confess to me that they do any portion of their training barefoot, but many more that are/were part of the “minimalist” shoe fad. Unfortunately many of those patients became patients of mine due to stress fractures or other overtraining types of injuries. More importantly, once these folks were treated and healed, many of these folks had biomechanical findings that are nicely addressed with functional foot orthotics (cavus or planus feet with secondary tendonopathies ...
By Dianne Mitchell on 2/12/2014 9:29 AM
What can you do to your orthotic rx to help decrease pain to this area!!
By Dianne Mitchell on 2/5/2014 9:24 AM
Diabetic with a new pair (about 1-2 months old) of accommodative orthotics. He came in with a large sub 1st met head and hallux base callus wanting options. No accommodations are on the devices, these are simple inserts. On exam this is a neuropathic diabetic, h/o ulcers to the feet, presently intact skin and a noted hallux rigidus. The patient is worried about re-ulcerating.
By Dianne Mitchell on 1/30/2014 9:21 AM
Patient presented with a painful met head (2nd met). He is already wearing some custom molded orthotics and someone had added a met pad to the device. He removed it due to increased pain. What was the problem? What are your options?
By Dianne Mitchell on 11/6/2013 9:41 AM
A patient presented to the office today with a pair of functional foot orthotics in his hands asking for a second opinion. He reports pain on the rim of the heel to both feet since about a week of wearing them. He stopped wearing them while waiting to see me.
My immediate thought was that the devices were too narrow in the heel cup. He stood on them for me and, yes, they were indeed too narrow. What can you do with this pair of orthotics to adjust them to fit the patient?
Couple options: (Note: These options would certainly depend on whether or not the patient's heel even fits in the heel cup! I make sure the heel fits in the heel cup non-weightbearing first.)
- raise the patient up out of the heel cup with a small heel lift underneath the top cover (Korex or poron works well)
- shallow out the depth of the heel cup (this requires a grinding wheel) this will effectively widen the orthotic

I also educate the patients and make sure they under ...
By Dianne Mitchell on 11/4/2013 9:03 AM
We see many diabetic foot ulcers in the office. My goal is to not only heal the wounds, BUT also prevent recurrent wounds. An example is: A diabetic foot ulcer on the plantar hallux base. On exam of the mechanics of this particular foot there is a functional hallux limitus. Once this ulceration is healed, what can you do to decrease the pressure to this region? AND prevent recurrence?

Couple thoughts on this one:
- functional foot orthotic with a diabetic top cover and addition, or integration, of a reverse Morton extension to allow plantarflexion of the 1st metatarsal. This will offer decreased pressure to the otherwise jammed hallux and the limitus.

- next, you must decrease the recurrent friction. The best way to do this is to add a piece of PTFE (minimal coefficient of friction) to the area that the hallux and first metatarsal head contact.

Together, these modifications will help to decrease the recurrence rate of the ulcerat ...
By Dianne Mitchell on 10/28/2013 9:36 AM
I order a fair amount of low profile athletic shoe (cleat/skate) or dress orthotics. A nice shell material option is carboplast. Whereas graphite is stiff and hard, carboplast offers some give, or flexibility, without failing and cracking and is still nice and thin. The lab uses a 2mm (175lbs or less) and 2.6mm (176lbs or more) thick carboplast. My patients are happier with this material and I especially enjoy carboplast more if I need to adjust it in the office. Try it out! The lab is substituting carboplast as the new "graphite" but I write in "carboplast" in the shell material box on the Prolab Prescription form.
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