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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 1/14/2010 6:34 PM
I had a patient present several months ago with diffuse midfoot osteoarthritis bilateral. Pain was present with most weightbearing activities and increased with exercise. Regardless of the joints involved in the midfoot, our goal with treatment is to limit the motion that causes pain.

Our first line of treatment was a custom foot orthosis with the following prescription:
  • Semi-rigid polypropylene
  • Deep heel cup
  • Wide width
  • Minimum cast fill
  • 0/0 rearfoot post

When trying to limit midfoot motion, be sure that your orthosis conforms very closely to the arch of foot and also acts to limit subtalar joint pronation.

These orthoses provided about 30% improvement of her symptoms, but she was still experiencing significant pain.

Our next line of treatment was the use of r ...
By Larry Huppin, DPM on 1/4/2010 4:14 PM
A patient presented today with bilateral pain on the plantar lateral foot with activity. His exam was significant for:
  • Cavus feet
  • Inverted RCSP with a positive Coleman Block test (by supporting the lateral forefoot the heel came to perpendicular)
  • Humongous styloids – plantar and lateral.
  • Pain to palpation on plantar styloids – no pain lateral.
He had a pair of orthoses that were not helping much. These devices were gapping extensively from his medial arch and although they had some accommodation plantarly for the styloids, it wasn’t nearly enough.

Our treatment goal is to reduce pressure under the styloid processes.

Here is the orthotic I prescribed:
By Larry Huppin, DPM on 11/30/2009 4:21 PM
A client question today:  

“I have a pt who is a marathon runner and is having B/L heel pain. He can control it somewhat by taping his foot (he was an athletic trainer) but as long as he keeps running, his heels bother him. He's 40 yrs old and weighs 160 pounds. He doesn't really hyper-pronate when he walks and his STJ is pretty stable. What type of material and top cover should I order with his orthotics? Would you recommend a certain heel cup depth for a runner? How much of a medial heel skive would you recommend? Any other tips for a running orthotic?? “

We recommend basing your orthoses more on the patient’s pathology rather than their activity. The activity comes into play when you are looking at how the device will fit into a shoe, but the pathology should drive your prescription.

The plantar fascia tightens when the first ray dorsiflexes (lengthening the foot a ...
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:
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