Case Studies

Orthosis for Calcaneal-Cuboid Pain

Thu, 12 Jan 2012 17:29:00 GMT

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:

Short First Metatarsal Post Surgery - Orthotic Considerations

Thu, 01 Dec 2011 16:02:00 GMT

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.

Foot Orthotics for Patient with First MTP Joint Arthrodesis and Metatarsalgia

Thu, 10 Nov 2011 14:56:00 GMT

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:

Orthotics for Cross-Country Ski Boots

Thu, 20 Oct 2011 15:52:00 GMT

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.

AFO For Calcaneus Gait

Thu, 30 Jun 2011 15:28:00 GMT

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.

Orthotic Prescription for Patient with Rheumatoid Nodules

Mon, 29 Nov 2010 21:01:00 GMT

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
Heel Cup Depth: If the heel is rectus, use a standard depth. If everted, use a deep heel cup.
Width: A wide orthosis will better transfer pressure off of the metatarsal heads onto the arch of the foot
Inversion: 2 degrees inversion will slightly raise the arch in order to better transfer pressure off of the metatarsal heads onto the arch
Post: EVA for a little shock absorption at heel contact
Topcover: Diabetic topcover to provide cushion
Forefoot Extension: 3mm Poron to sulcus for additional met head cushion
Special Additions: Metatarsal Bar to transfer more pressure off of the met heads.

We then suggest letting the patient wear the orthosis for a couple weeks. You will then see indentations in the cover where excessive pressure is occurring under 1 and 5. At that time you can add a piece of 3mm Korex under met heads 2, 3, 4 in order to further unweight 1 and 5. In addition you can build up the metatarsal bar as necessary.

If you have questions on orthotic prescriptions for any pathology, ProLab clients have no-charge access to our medical consultants.

Extra Depth Steel Toed Boots

Thu, 14 Oct 2010 14:14:00 GMT

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.

Our solution was to recommend the use of the PW Minor Super Depth Steel Toe Work Boots. The P.W. Minor Hercules ST has added depth and extra space added to the forefoot area to accommodate custom orthotics. It comes in widths up to 14 3E. We referred him to a local pedorthic shoe store that carries PW Minor. They will likely have to order the boots after sizing him and then add some fillers to the left boot as it doesn’t feel too large.

If you don’t have a local shoe store that can get the boots, they can also be ordered from HealthyFeetStore.com. This podiatrist owned site offers mismatched sizes as part of their Different Sized Feet Program.

Can Orthoses Help Digital Keratomas?

Tue, 25 May 2010 01:16:00 GMT

I had a client call with the following question today:

QUESTION:
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?

ANSWER
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 patient has worn the orthsis for a few weeks, these covers will show an impression/indentation in areas of increased pressure. This impression will act as a guide for you to add accommodations for the callus. Here are two ideas.

1. Using a piece of Poron, create a crest pad by gluing the Poron onto the bottom of the cover, so that it will lie in the sulcus of the toes when the patient stands on the device. Like a crest pad, this may help straighten the toes as the patient stands on the device..

2. Using Poron or Korex add a horseshoe or doughnut accommodation around the distal tip of the toe. The impression on the topcover will guide you as to exactly where the accommodation should go.

Can Diagnostic Ultrasound Change Your Orthotic Rx?

Thu, 06 May 2010 14:39:00 GMT

In the year we have been using diagnostic ultrasound (US)in our office, I’ve made changes in some orthotic prescriptions based on US findings. In particular, US has affected my orthotic prescription in those cases where there is thickening of the plantar fascia directly plantar to the calcaneus.

When US indicates that there is excessive inflammation / thickening of the plantar fascia directly plantar to the calcaneus (rather than at the medial tubercle where we primarily see thickening of the fascia) I’ve started adding extra cushion to my orthotic devices. I’ll usually prescribe one of our Pathology Specific plantar fasciitis orthoses, but add a Poron heel pad to the device. This has been a effective addition to the orthoses.

Orthotic Troubleshooting: Heel Cup Irritation

Thu, 08 Apr 2010 16:00:00 GMT

A client emailed some pictures today of a patient who was having heel cup irritation from his orthoses. You can see the pictures below. He wanted to know what we could do to fix the problem.

Unfortunately, there is no way to effectively adjust this orthosis to reduce heel irritation. The device will need to be redone with a more heel expansion on the positive to create a wider heel cup.

This problem occurs because the non-weightbearing cast does not indicate how wide the fat pad is during stance. This is a bigger problem for obese patients simply because they have more fat to displace upon weightbearing.

To avoid this problem, we ask that you measure the weightbearing width of your patients heels. In fact, we would like our clients to provide this information for EVERY PATIENT. You can use the link below to buy the caliper I use in my office.

Click here to purchase the caliper I use in my office. It costs about $15 at Amazon.