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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 4/8/2010 8:00 AM
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 ...
By Larry Huppin, DPM on 4/1/2010 1:33 PM
We had a patient present earlier this week who had a prominent plantar fascia that was being irritated by her new orthoses. Below is detailed our standard troubleshooting plan for creating a plantar fascial groove in an orthosis that was made without one:
  1. If you have an EVA cover on the orthosis, leave it on. If the cover is anything other than EVA, remove it.
  2. If there is on cover, glue 3mm EVA or Poron to the dorsum of the orthosis
  3. Mark the plantar fascia with lipstick
  4. Line the orthosis up with the foot and press it into the foot in order to transfer the lipstick mark to the orthosis
  5. Use a Ticro Cone to grind a groove into the orthosis
  6. Put a thin cover on top of the device.
By Larry Huppin, DPM on 3/1/2010 3:07 PM
I had three new patients today who presented with relatively new foot orthoses received elsewhere. All were continuing to have pain and had questions on whether the orthoses were appropriate for their feet. Two of the patients had plantar fasciitis and the other metatarsalgia.

Each of the three orthoses were gapping significantly from the arch of the feet and one was flexible enough that it collapsed entirely with finger pressure.

Significant literature supports the use of “total contact orthoses” that conform closely to the arch of the foot to both reduce tension on the plantar fasica and to transfer pressure off of the forefoot. None of these orthoses were conforming to the arch of their respective feet.

This is sometimes a difficult situation. The patient has already paid a lot of money for custom orthoses and no ...
By Larry Huppin, DPM on 2/18/2010 5:13 PM
I consulted with a client today who had a patient with peroneus brevis enthesiopathy.

The goal with orthotic therapy in these cases is to increase the force that the orthotic is exerting on the foot lateral to the subtalar joint axis. Since the peroneus brevis is acting to evert the foot, our orthoses should assist this action in order to reduce the need to fire this muscle. Not suprisingly, it is often patients who are laterally unstable who experience this problem.

CASTING:
Remove soft tissue varus (supinatus) when taking the negative cast. This is imperative as it results in greater forefoot valgus in the negative cast and ultimately in the orthosis. This results in an orthosis that will better support the lateral forefoot and thus reduce the need for the PB to fire. Watch our casting video

PRESCRIPTION:
  • Material: A semi-rigid polypropylene. Either direct-milled or vacuum formed.& ...
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:  

QUESTION
“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?? “

ANSWER
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:

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