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Author: Larry Huppin, DPM Created: 8/6/2009 8:04 AM
Discussion of orthotic therapy for specific patients

By Larry Huppin, DPM on 11/23/2009 5:54 PM
I saw a 120 lb female patient back today who presented last year with medial malleolar pain when hiking. She was an active hiker, so this was significantly hindering her ability to enjoy the outdoors.

She didn’t have a particularly large malleolas, but she was quite pronated. Both heels were everted about 10 degrees in stance. As the feet pronated, the medial ankle rolled medially resulting in increased pressure of the malleolas against the medial wall of the boot.

Our treatment goal was to decrease the pressure between the boot and malleolas by limiting eversion of the heel.

Here is our prescription:
By Larry Huppin, DPM on 11/21/2009 11:51 AM
A patient presented to my office yesterday complaining of lateral foot pain left only. He had a history of clubfoot at birth that was only partially corrected surgically. He now has a left foot that has:
• Inverted heel in stance. Heel sits about 10 degrees inverted. Coleman block test is negative in that I could not reduce the inverted position by supporting the lateral forefoot.
• Equinus. Unless the knee is placed into recurvatum, the heel is about 1 cm off of the ground.
• Extremely high arch and plantarflexed first ray.
• Planatar prominence of the 5th metatarsal base

Overall, pretty classic findings for a clubfoot.

His only complaint is pain under the styloid process. He has never had orthotics, nor have they been recommended.

Our treatment goal is to reduce pressure on the plantar 5th metatarsal base. This is what was prescribed for the left foot:

By Larry Huppin, DPM on 11/5/2009 4:03 PM
I have a patient with PTTD for whom I made a ProLab PTD Pathology Specific Orthosis. It has worked great and she is pain free when she wears them. As you may know, however, this is a pretty bulky device and fitting it into anything other than a lace-up shoe is difficult. My patient wants to be able to occasionally wear somewhat dressier shoes and was wondering if we could make her a dress orthosis.

Normally, this is not only easy, but expected. About 70% of my female patients will end up with two pair of orthoses. A full sized pair for exercise and a smaller pair for dressier shoes. The PTD foot, however, is so dramatically pronated that a standard dr ...
By Larry Huppin, DPM on 10/22/2009 7:07 AM
I have a patient who, by history, seems to have had a triple done years ago by an orthopedist ...
By Larry Huppin, DPM on 9/14/2009 2:00 PM
Today we are going to look at a case study from my office – one that I find a bit disturbing in that two podiatrists wanted to perform surgical exploration on a problem that was easily handled with orthotic therapy. The patient is a 49 year old podiatrist (yes, a podiatrist) with a primarily CNC practice.

He has a 7 month history of pain at the plantar base of the 5th metatarsal. He reports a history of stepping on some glass about 8 months ago. A friend who is a physician removed a glass fragment, but since then he has had pain on the plantar foot near the 5th met/cuboid joint. He had both MRI and diagnostic ultrasound – both of which were negative for evidence of foreign body.

He has since seen two local podiatrists. Both of whom advised surgery to explore the area for foreign body.

His exam was significant for a cavus foot structure with a plantarly prominent styloid process right. Pain to palpation was present on the right ...
By Larry Huppin, DPM on 9/10/2009 1:32 PM
A 53 year old woman presented to the office this week with a primary complaint of pain under the first met head right. Her history was significant for an ankle fusion 2 years ago.

Exam was significant for pain on the tibial sesamoid and the fact that she as fused in 5 degrees of plantarflexion. In stance, her heel would not touch the ground unless her knee was in recurvatum. When I placed her knee in a mildly flexed (normal stance) position, I measured the heel off the ground by 9mm.

She wants to be active. She also would like to wear cute shoes occasionally.

Treatment Goal: Reduce pressure on the sesamoids by transferring force to the medial arch and by getting the heel to bear weight

Orthotic prescription:
By Larry Huppin, DPM on 9/3/2009 2:33 PM
I had a 9 yo soccer player in my office today with a complaint of medial ankle pain with activity. She was brought in by her mother who was frustrated with the treatment that had been provided so far. The patient, we’ll call her Cindy Lou, has been active in sports since age 4 and has never been one to complain of pain except for this problem. Now she has been having medial ankle pain for over 4 months. They have seen the pediatrician several times and he has recommended Tylenol and ice. They purchased more stable soccer shoes and some Superfeet arch supports – which helped a little. When they presented again to the pediatrician he told them to it was “growing pains”, don’t worry about it and to stop activity if it continued.

Frustrated, they were referred to us by the mother of one of Cindy Lou’s soccer teammates. Her pain was medial ankle behind the malleolas and posterior-medial leg. There is pain to palpation along the course of the posterior tibial tendon.

By Larry Huppin, DPM on 8/31/2009 2:19 PM
A patient presented to my office today for follow-up on her posterior tibialis tendonitis.  On the last visit we had dispensed a pair of ProLab PTTD orthoses to control her extreme pronation.  She was doing great.  She loves the orthoses and all of her tendon pain has resolved.   The only problem is that she has developed some blisters pn the left foot in the area of the talo-naviuclar joint plantarly. 

The orthoses appear to fit well and they do not appear to be too narrow (which could lead to blistering as the medial foot can ride over the medial edge of the orthosis.

This is a relatively easy problem to troubleshoot.   What we find works well is to simply increase the flex of the orthosis in t ...
By Larry Huppin, DPM on 8/24/2009 1:26 PM
A client called today with a question about a patient with OA of the left ankle joint. His biomechanical examination was significant for a 10 degree everted RCSP. Xrays show a valgus angulation of the ankle joint with increased moment through the lateral ankle and decreased moment medially.

Our goal with the orthosis to reduce the RCSP and bring the heel as close as possible to perpendicular in order to equalize force across the ankle joint. Thus, this will be an aggressive orthotic prescription. In fact, I would recommend warning the patient that the orthosis may have to be adjusted if the patient experiences uncomfortable pressure on the foot. The patient would not likely tolerate an orthosis that applied enough force to bring the heel all the way to perpendicular, but our prescription will act to bring it as close as possible to perpendicular.

Here is what we recommended:
By Larry Huppin, DPM on 7/23/2009 1:46 PM
I had a patient present yesterday with complaint of a 10 year history of right-only lateral knee pain when running. Pain would occur on every run after 20 - 30 minutes. He never went more than 30 minutes without pain occurring. Biomechanical exam and knee exam were both normal except for a slightly under-pronated foot (RCSP was slightly inverted) He has had a complete work-up of the knee by an orthopedist and exam was normal.
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