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

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.
By Dianne Mitchell on 10/24/2013 9:28 AM
Patient came in today with a painful metatarsalgia to the central metatarsals 2-3-4. She happened to be wearing her functional foot orthotics which appeared appropriate for her foot shape and type. What can you do in the office to help with pain?

Couple of options:

- add a top cover for padding
- add a forefoot extension of simple poron or soft EVA for paddling beneath the top cover for reinforced padding
- add a metatarsal bar just proximal to the metatarsal heads in order to attempt offloading the painful metatarsal heads

I usually trial these above options in the above order.

I also examine the patient for equinus deformity and start a stretching program.
By Dianne Mitchell on 10/21/2013 9:16 AM
I frequently see patients in the office with under-corrected orthotics. Many of these devices simply do not contour the arch. Instead there is a gap between the arch of the orthotic and the patients arch. One in-office fix is to add arch fill to the device. I use Korex to add height to the top of the orthotic to fill in the gap. Once the gap has been filled in, you can add a fresh top cover.
See the September issue of Podiatry Management for additional in-office tricks!
By Dianne Mitchell on 10/17/2013 9:04 AM
Molded a patient today in the office with two rather different feet. One cavovarus foot with a bunion deformity versus the contra-lateral foot that has a resting calcaneal stance position that is nearly perpendicular (slight eversion) to the ground without a bunion deformity.
When writing the orthotic prescription I like to make sure the lab understands that those two pretty different looking casts are correct and should be different from each other to yield two different orthotic devices. You can let the lab know this information on your prescription form both by writing the diagnoses at the top of the form and also marking the YES box to denote the asymmetry.
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 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.
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