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Author: Larry Huppin, DPM Created: 6/20/2009 9:45 AM
This blog is designed to provide foot orthosis and ankle-foot orthosis practitioners and students with unique and practical information on foot orthotic therapy. We will provide insight on what’s new in the literature regarding orthotic therapy, orthotic hints and pearls, practice managment information, our opinions on new technology and even some thoughts on controversial topics in the foot orthotic industry. We welcome input and suggestions from orthotic practitoners and others interested in orthotic therapy. This is, however, a discussion on the practice of orthotic therapy and not designed as site to provide medical information to the public.

By Larry Huppin, DPM on 3/28/2011 6:34 AM
I had a client call today with a question regarding an orthotic prescription for a patient with functional hallux limitus affecting one foot and a rather severe hallux rigidus affecting the other. The right foot had less than 5 degrees of dorsiflexion available at the first MPJ, while the left had full range of motion and just a little dorsal exostosis.

The orthotic for the foot with hallux limitus is fairly straightforward. In this situation, we want to design the device to enhance motion in the first MPJ and decrease compression within that joint. You can read more about orthoses for hallux limitus here.

The orthosis for hallux rigidus is a little more complicated. In the presence of hallux rigidus, some patients will feel better if we use the orthosis to dec
By Larry Huppin, DPM on 3/24/2011 1:06 PM
Proper casting position is critical when you are prescribing a Functional AFO (FAFO). Recently we have been seeing a number of FAFO casts coming in with excessive plantarflexion. These casts are unusable and we have to ask the doctor to redo the cast.  This, of course, is inconvenient for you and your patient. 

For best function and comfort, the hinges of a FAFO must be placed so that they are directly over the distal tip of each malleolus. This ensures that the brace moves naturally with the ankle joint and dramatically reduces the possibility that a patient will experience malleolar irritation.

If a cast for a FAFO is taken with the foot plantarflexed to the leg, the hinge ...
By Larry Huppin, DPM on 3/21/2011 8:33 AM
A client sent in this question yesterday. My answers are in italics.

I have a patient who is a postal worker and has a chronic sub 4th metatarsal head nucleated callus. He has cavus foot type, fat pad atrophy and supinates when walking. How successful are custom orthotics with a metatarsal bar in treating this condition. Would you recommended any other modifications like a poron pad under the 4th MPJ?

A number of studies have shown that, if prescribed correctly, orthotics are very effective at reducing pressure under the metatarsal heads. Most studies show that orthoses that conform very close to the arch of the foot are most effective at reducing pressure. This would require a minimum cast fill and about 2 degrees of inversion. Metatarsal pads have also been shown to further reduce metatarsal head pressure. A study by Mueller showed that the met pad works best when the thickest portion is about 1 cm proximal to the point of maximum pain. We hav
By Larry Huppin, DPM on 3/17/2011 2:10 PM
 Proper casting position is critical when you are prescribing a gauntlet AFO. Today we want to focus on the error we see most often – that is excessive plantarflexion at the ankle in the negative cast. It’s absolutely critical that the cast be taken with the foot at 90 degrees to the leg. In fact, if the foot is plantarflexed to the leg in the cast, then the cast in unusable.

Having the ankle plantarflexed excessively is the casting error we see most often because it is so easy for it to happen. When taking a cast for a gauntlet AFO your patient will be in a sitting position with the thigh parallel to the floor, the leg at 90 degrees to the thigh and the foot at 90 degrees to the leg. If the foot simply slides forward a few millimeters during casting, then the resultant cast will have the foot plantarflexed to the leg. If we receive this cast at the lab we have no choice but to throw it away and ask you to start over. This is inconvenien
By Larry Huppin, DPM on 3/14/2011 12:36 PM
 Medial Tibial Stress Syndrome  (MTSS) is a condition seen in runners and is fairly rare in non-runners. Here is a quick overview of the pathology with some orthotic prescription recommendations for a device to be worn in running shoes.

Known commonly as tibial stress syndrome, tibial fasciitis, shin splints and soleus syndrome, MTSS is characterized by pain / tenderness distal aspect of medial border of the tibia.

Anatomical Etiologies
  • Contrary to common assumptions, posterior tibialis is not likely involved; it has a more lateral tibial origin
  • Likely anatomic etiology is the fascial insertion of the medial soleus
  • Oth ...
By Larry Huppin, DPM on 3/10/2011 10:36 PM
I had a client call today asking about an orthosis prescription for a patient with peroneal neuropathy with significant weakness. The patient had found he liked having a contralateral prefabricated orthotic under that foot. It wasn't comfortable, but he liked the support.

Our goal for the prescription is to apply an eversion force to the foot in order to support the weak evertors and also to transfer force from the lateral foot to the medial foot. This is, by the way, a good example of using the tissue stress theory of orthotic function to figure out a prescription.

Here is the prescription we came up with:
By Larry Huppin, DPM on 3/7/2011 12:10 PM
Will foot orthoses help your patient with patellofemoral pain? The key to predicting this seems to be identifying which specific patients with PFPS are most likely to benefit from orthotic therapy. This is the subject of a recent article in Lower Extremity Review which we are recommending to ProLab clients.

Significant research (referenced in the LER article) shows that some, but not all, individuals with PFPS benefit from foot orthoses. From the article:

Previous research from two separate studies 26,34 indicates that when individuals with PFPS are prescribed prefa ...
By Larry Huppin, DPM on 3/3/2011 11:14 AM
One aspect of the health reform bill that may affect you is an annual fee (2.3% tax) imposed on medical device manufacturers starting in 2013. At this time it is unclear if the tax will apply to foot orthotic manufacturers, but it looks like it may apply to a number of orthotic and DME manufacturers and importers.

Certain devices, including eyeglasses, contact lenses and hearing aids, were specifically exempted. Also exempted was "any other medical device determined by the Secretary to be of a type which is generally purchased by the general public for personal use".  This is an important exemption that could apply to a number of foot orthotics. This language and other parts of the legislation, however, could also be interpreted to include cust ...
By Larry Huppin, DPM on 2/28/2011 12:21 PM
Last week I wrote about the new orthotic therapy textbook "Recent Advances in Orthotic Therapy: Improving Clinical Outcomes with a Pathology-Specific Approach" by Paul Scherer, DPM.

I have had a couple of questions since then about what exactly is covered in the book. Below is a list of chapters. In addition, a version of the chapter on orthoses for metatarsalgia was published as an article in the latest issue of Lower Extremity Review. You can read that article here.


Chapters:
By Larry Huppin, DPM on 2/24/2011 2:07 PM
All of us at ProLab are proud to announce that Paul Scherer, DPM is the author of a new textbook on orthotic therapy:
"Recent Advances in Orthotic Therapy: Improving Clinical Outcomes with a Pathology-Specific Approach" by Paul Scherer, DPM. Published by Lower Extremity Review.

The book is focused on evidence based orthotic therapy and organized in a pathology specfic approach. Paul has done an exceptional job of pulling together the available scientific research to support the use of custom foot orthoses for different pathologies. Each chapter includes a guide on recommended orthotic prescription writing for functional orthoses ...
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