1 Novel Orthotic Adjustments in the Office or the Lab Picture courtesy Jeff Root, Root Orthotic Labs CFPM Conference, Niagara Falls, ON November 6-8, 2014 Private Practice -Whitby & Peterborough, ON Professor Chiropody Faculty - Michener Institute Council Member - College of Chiropodists of Ontario Professional Advisory Board - Paris Orthotics Peter G. Guy B.Sc., D.Ch. Even the best designed and properly casted foot orthoses may require a modification The inability to perform an in- office modification can leave your patient dissatisfied and without their foot orthoses. http://images.huffingtonpost.com/2010-11- 15-ANGERSHUTTER1.jpg Patient satisfaction can be enhanced when the appropriate orthotic modification can be performed in office in a timely fashion. In office modifications will increase patient satisfaction and outcomes. The main goal of orthotic therapy is to address the patient’s foot complaint by reducing the tissue stresses that causes pain.
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2014 CFPM Orthotic modification - CFPM Home · PDF file• Hour glass design • Heel seat depth ... Add EVA fill to stabilize device/ increase rigidity ... laminated at the distal
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Novel Orthotic Adjustments in the Officeor the Lab
Picture courtesy Jeff Root,Root Orthotic Labs
CFPM Conference, Niagara Falls, ONNovember 6-8, 2014
Private Practice -Whitby & Peterborough, ONProfessor Chiropody Faculty - Michener InstituteCouncil Member - College of Chiropodists of OntarioProfessional Advisory Board - Paris Orthotics
Peter G. Guy B.Sc., D.Ch.
Even the best designed andproperly casted foot orthosesmay require a modification
The inability toperform an in-officemodification canleave yourpatientdissatisfied andwithout their footorthoses.
It has been postulated that each of thebody’s tissues has a zone of optimal stressand the tissue must be loaded within thiszone to remain healthy”.
http://thesportsphysio.wordpress.com/2013/09/29/the-myths-of-foot-orthoses-a-guest-article-by-ian-griffiths/Picture courtesy of Kevin Kirby DPM
Mid-tarsal joint
CalfmusclesTibialis posterior m.
Body weight
1st toe joint
The plantar fascia willresist the foot bendingduring heel rise.
Niki: H.N., Ching R.P., Kiser P., Sangeorzan B.J. “The Effect of Posterior Tibial Tendon Dysfunctionon Hindfoot Kinematics.” Foot and Ankle 22:292-300, 2001
Mid-tarsal joint
Calfmuscles
Tibialis posterior m.
Body weight
1st toe joint
Plantar fascia, plantarligaments, and plantarmuscles will stretch whilebones will compress
Foot orthoses are most likely alteringthe forces applied to tissues by…..
1. Altering the magnitude ofthe reaction forces
2. Altering the vector of thereaction forces
3. Altering the temporalpatterns of the reactionforces
4. Altering the plantarlocations of the reactionforces acting on the foot.
Orthotic reaction forces appear to affectthe muscle reaction forces
Or there maybe a neuromotor response between afferent inputand efferent output due to the mechanical orthoses reaction forceacting on the plantar skin via proprioception.
Is Muscle Activity Influenced By FootAnatomy and/or Foot Orthoses?Paris Evening Seminar Fall 2012 ,Christopher MacLean, Ph.D.
The orthotic reaction forces (kineticvariables) are probably achieved viathe following orthotic design features.
• The surface geometry of theorthoses (shape/contour)
• The load-deformationcharacteristics of theorthoses (stiffness)
• The frictional characteristicsof the orthoses (think topcover selection)
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Any orthotic modification weintroduce is changing the surfacegeometry, device stiffness orcushioning
Cast modifications performed at labas per your prescription.
• Expansions
• Fill
• Intrinsic forefootposition
• Heel expansion
• Heel pitch
• Arch contour
• Wedging
Shell modifications performed at the lab• Thickness and
Topcover modifications that can befabricated by the lab or performed inoffice
Type of fabric/material
Thickness
Length
Met. Dome
Preload hallux
Morton’s extension
Reverse Morton’s
Gluing of topcover
Lesion accommodations
Shell Flexibility Tips
Understand the materials you choosealone or in combination
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Postingthe shell
increasesthe
rigidity ofthe shell
The shape of the shell due to patient foottype and heel depth will dictate the flexibilityof the shell.
Simple fix to increase shellflexibility is to lower the heel cupheight
Is the prescribed foot orthotic shankdependent or independentA shank stiffens the shoe underthe arch which makes themiddle portion of the shoe moreresistant to torsion and flexion.
EVA devices are shank dependentas well as most prefabs
Mitchell, 10 Orthotic Modifications You Can Perform in the Office Pod Mang Sept 2013
Plantar fascia accommodation corkonlay
Mitchell, 10 Orthotic Modifications You Can Perform in the Office Pod Mang Sept 2013
Plantar fascial accommodation shellgrind
Photos courtesy of Larry Huppin DPM
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Marking the plantar fascia prior tocasting
Picture courtesy Jeff Root, Root Orthotic Labs
Cluffy™ wedge is helpful when othermethods of getting the 1st ray toplantarflex don’t appear to be effective
Clough Eight Methods of Improving Orthotic Outcomes Pod Mang Sept 2010
The valgus onlay by John Weed is agood in office modification to use to tryto salvage an orthosis that isn’tproviding enough valguscorrection/support in the forefoot
.
Picture courtesy Jeff Root,Root Orthotic Labs
John Weed valgus onlay modificationwas used prior to the heel skivemodificationJohn Weed observed somepatients pronated excessivelyoff of their orthoses hetheorized these patients werenot controlled well enoughsince they were pronated atSTJ hence the MTJ wasunstable. He developed thevalgus inlay. The forefoot isdirected into valgus position.
“Richie wedgy” helps to offload theplantar fascia
Use 1/8 inch Korea and skive all three sides except lateral withheight point under mid shaft of the fifth metatarsal.
Pictures courtesy Doug Richie DPM
Sarrafarian Twisted Plate
Sarrafian SK Functional Characteristics of the Foot and Plantar Aponeurosis underTibiotalar Loading Foot & Ankle l 8,(1) 1987
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Valgus wedges reduce the strain onthe plantar fascia
Kogler D.F et alThe Influence of Medial and Lateral Placement of Orthotic Wedges on Loading of thePlantar Aponeurosis. An in Vitro Study J Bone Joint Surg Am, 1999 Oct 01;81(10):1403-13
Case of the Internal MetatarsalRocker
Combination of poly-carbon stiffenerand EVA rocker
Shoe volume modifications
Medial RF post only
• Reduces devicecontrol at heelstrike but maintainsmedial controlthrough midstance
• Reduces devicevolume, ofteneffective in designof dress devices
Lateral half of labstandard extrinsic RF postis removed along withstrikeplate
Posterior Heel Bumper
• 3mm to 6mm EVA wrappedaround heel cup of deviceto advance shell distallywithin shoe
• Full EVA thicknessmaintained at posterioraspect of heel and taperedto 0mm at medial andlateral edges
• Effective when dealing withshoe heel counters whichadvance the heel slightlyforward in the shoe
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Heel rim irritation modifications
Mitchell, 10 Orthotic Modifications You Can Perform in the Office Pod Mang Sept 2013
You can also grind the inside edge ofheel cup rim with dremel burr
Miscellaneous Modifications
Jobs that involve carrying, pushing andpulling loads on uneven surfacesrequire stabilization• High top boots provide most of
stabilization
• Steel shank if using ladders orshovels
• Orthotic device with flat posts,deeper heel cups and wider shell
• 3mm neoprene or Poron/leathertop cover
• Restaurant and retail workerssemi-flexible or flexible device witharch reinforcement along withpadded top cover
Jobs involving standing in place forlengthy periods require offloading fromcalcaneus and metatarsals heads
• Shell to be inversely flexible to thefirmness of the shoe and the surface
• Other factors: foot stiffness, amount ofequinus, weight and age
• Polypro, EVA or Plastazote #3
• Deep heel cups and wide shell withcongruent medial and lateral arch contour,
• Non bevelled anterior edge or met bar
• 3 to 6 mm neoprene or PPT/leather topcover
• In some cases a lower arch with moreshell flexibility is required but may notsuitable for exercise.
Top cover bunion accommodation
Pictures courtesy of Brian Cragg BSc DCh
Superthotic
• Direct milled shell,3mm puff topcoverto toes, agoflexbottom cover totoes
• Useful for devicesused in extremeconditions(temperature/dirt/debris exposure)
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Bottom covers help to stiffen top coversto allow for easy transfer in/out ofshoes
• Agoflex, vinyl, 1.5mm cork/puff bottom covers are effective
• Bottom covers also create sandwich effect at distal end of shellwhich improves component durability via improved lamination
Heel bursitis or heel spuraccommodation
Picture courtesy of Kevin Kirby DPM
A Simple Cure for Morton’s Neuralgia
Journal of the American Podiatric Medical Association Volume 90 • Number 2 • February 2000
Acknowledgments
Brian Cragg
Larry Huppin
Paul Paris
Doug Richie
Jeff Root
Lief Royle
Books by Kevin Kirby DPM thatdiscuss and illustrate orthoticmodificationsKirby KA: Foot and Lower Extremity Biomechanics: A Ten Year Collectionof Precision Intricast Newsletters. Precision Intricast, Inc., Payson, Arizona,1997.
Kirby KA: Foot and Lower Extremity Biomechanics II: Precision IntricastNewsletters, 1997-2002. Precision Intricast, Inc., Payson, Arizona, 2002.
Kirby KA: Foot and Lower Extremity Biomechanics III: Precision IntricastNewsletters, 2002-2008. Precision Intricast, Inc., Payson, AZ, 2009
Book 4 will be out this January
http://www.dpmlab.com/html/bookreview.html
In office modifications will increase patientsatisfaction and word of mouth referrals toyour practice.