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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 11/10/2011 6:56 AM
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:
By Larry Huppin, DPM on 10/20/2011 7:52 AM
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.
By Larry Huppin, DPM on 6/30/2011 7:28 AM
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.
By Larry Huppin, DPM on 11/29/2010 1:01 PM
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
By Larry Huppin, DPM on 10/14/2010 6:14 AM
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.

By Larry Huppin, DPM on 5/24/2010 5:16 PM
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 patie ...
By Larry Huppin, DPM on 5/6/2010 6:39 AM
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
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 ...
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