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Novel Orthotic Adjustments in the Officeor the Lab

Picture courtesy Jeff Root,Root Orthotic Labs

CFPM Conference, Niagara Falls, ONNovember 6-8, 2014

Private Practice -Whitby & Peterborough, ONProfessor Chiropody Faculty - Michener InstituteCouncil Member - College of Chiropodists of OntarioProfessional Advisory Board - Paris Orthotics

Peter G. Guy B.Sc., D.Ch.

Even the best designed andproperly casted foot orthosesmay require a modification

The inability toperform an in-officemodification canleave yourpatientdissatisfied andwithout their footorthoses.

http://images.huffingtonpost.com/2010-11-15-ANGERSHUTTER1.jpg

Patient satisfaction can be enhancedwhen the appropriate orthoticmodification can be performed inoffice in a timely fashion.

In office modifications will increasepatient satisfaction and outcomes.

The main goal of orthotictherapy is to address thepatient’s foot complaint byreducing the tissuestresses that causes pain.

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“Tissue dysfunction couldbe said to occur when:

1. a healthy tissue isloaded in an‘abnormal’ way,

2. an unhealthy tissue isloaded in a ‘normal’way or worst of all

3. an unhealthy tissue isloaded in an‘abnormal’ way”.

http://thesportsphysio.wordpress.com/2013/09/29/the-myths-of-foot-orthoses-a-guest-article-by-ian-griffiths/

It has been postulated that each of thebody’s tissues has a zone of optimal stressand the tissue must be loaded within thiszone to remain healthy”.

http://thesportsphysio.wordpress.com/2013/09/29/the-myths-of-foot-orthoses-a-guest-article-by-ian-griffiths/Picture courtesy of Kevin Kirby DPM

Mid-tarsal joint

CalfmusclesTibialis posterior m.

Body weight

1st toe joint

The plantar fascia willresist the foot bendingduring heel rise.

Niki: H.N., Ching R.P., Kiser P., Sangeorzan B.J. “The Effect of Posterior Tibial Tendon Dysfunctionon Hindfoot Kinematics.” Foot and Ankle 22:292-300, 2001

Mid-tarsal joint

Calfmuscles

Tibialis posterior m.

Body weight

1st toe joint

Plantar fascia, plantarligaments, and plantarmuscles will stretch whilebones will compress

Foot orthoses are most likely alteringthe forces applied to tissues by…..

1. Altering the magnitude ofthe reaction forces

2. Altering the vector of thereaction forces

3. Altering the temporalpatterns of the reactionforces

4. Altering the plantarlocations of the reactionforces acting on the foot.

Orthotic reaction forces appear to affectthe muscle reaction forces

Or there maybe a neuromotor response between afferent inputand efferent output due to the mechanical orthoses reaction forceacting on the plantar skin via proprioception.

Is Muscle Activity Influenced By FootAnatomy and/or Foot Orthoses?Paris Evening Seminar Fall 2012 ,Christopher MacLean, Ph.D.

The orthotic reaction forces (kineticvariables) are probably achieved viathe following orthotic design features.

• The surface geometry of theorthoses (shape/contour)

• The load-deformationcharacteristics of theorthoses (stiffness)

• The frictional characteristicsof the orthoses (think topcover selection)

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Any orthotic modification weintroduce is changing the surfacegeometry, device stiffness orcushioning

Cast modifications performed at labas per your prescription.

• Expansions

• Fill

• Intrinsic forefootposition

• Heel expansion

• Heel pitch

• Arch contour

• Wedging

Shell modifications performed at the lab• Thickness and

flexibility of material

• Arch flexibility

• 1st ray flexibility

• Arch reinforcement

• Anterior edge length

• Forefoot width

• 1st ray cut out

• Heel post flare

• Heel spur aperture

• Type of post

• Cobra design

• Non beveled anterior edge• Low bulk grind• Hour glass design• Heel seat depth• Heel raise• Sweet spot• Fascial groove

Topcover modifications that can befabricated by the lab or performed inoffice

Type of fabric/material

Thickness

Length

Met. Dome

Preload hallux

Morton’s extension

Reverse Morton’s

Gluing of topcover

Lesion accommodations

Shell Flexibility Tips

Understand the materials you choosealone or in combination

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Postingthe shell

increasesthe

rigidity ofthe shell

The shape of the shell due to patient foottype and heel depth will dictate the flexibilityof the shell.

Simple fix to increase shellflexibility is to lower the heel cupheight

Is the prescribed foot orthotic shankdependent or independentA shank stiffens the shoe underthe arch which makes themiddle portion of the shoe moreresistant to torsion and flexion.

EVA devices are shank dependentas well as most prefabs

http://runblogger.com/images/2012/03/skechers-go-bionic-review-lightweight-zero-drop-and-ultra-flexible-running-shoe-6.jpg

Plastic CFOs are shank independent

The top 5 adjustments requested withinthe first few months after manufacture:

1. Remove/lower met.pads

2. Lower/raise MLA height

3. Extend top cover totoes

4. Reduce shell width to fitshoes / trace / insole/old devices provided

5. Add EVA fill to stabilizedevice/ increase rigidity

List of requested modifications receivedthat could be done in office.

1. Remove RF post/strike plates

2. Trim top cover to matchinsole/shoe provided

3. Increase sidecut/undercut

4. Remove/reduce met pads

5. Hourglass shells

6. Add 1st met cut-out

7. Trim top cover to sulcus ormet’s (from full length)

8. Remove rigid 1st extension

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Some other modifications performed bythe lab on returned foot orthoses

• Shell accommodations (plantar fascia, navicular,fibroma)

• Extrinsic post modifications (skive in heel post,modify motion)

If you talk to a lab owner aboutsuccessful orthotic therapy they willtell you……

Keep it simple !

Casting is Key

Understand your labs arch fill parameters

If you use heel bisections isyour technique standardized

What you need to get started Orange sol™ dissolve it productswill help to remove glue from shell

The Orthotic Modification MatrixMedialColumnOverload

LateralColumnOverload

Increasedmetatarsal headpressure

1st MPJ/raymods

Shoe Volumemods

Misc. mods

AdvancedmedialRF post

5th metcutout

Extrinsic andintrinsic. metraise

Morton’s andReverse’Mortons

Medial RFpost

Buniontopcover

Extendedmedialtopcover

Vertical grindto lateral RFpost

Met pad Plantarfascialaccom

Posteriorheel bumper

Superthotic

Verticalgrind ofRF post

Peronealtendinopathy

Capsulitis/

Plantar plateinjury

Cluffywedge

Heel rimirritation

Bottomcovers

Misc. mods

KirbySkive andInvertedRF

Sometimesan footorthoticwon’t do !

Request distaltopcoverunglued or Preglue shell andtopcover

John Weedor Richiewedgy for ↓ load on PlFascia

Patients whocarry, pushand pull loadson unevensurfaces

Proximalpl.fasciitis/heel spurmod/heelbubble

Cuboid pad ↑ forefoot pressure fromkneeling,stooping orsquatting

The internalmet rocker

Patients whomust stand inplace forlengthyperiods

Morton’sneuromamodification

Acknowledgements Medial Column Overload

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Advanced medial or lateral RF post

• RF post extendedanterior - medially oranterior - laterally intoeither the medial orlateral long arch

• Increased RF controlthrough increasedshell stability andrigidity

Topcover valgus extension with orwithout valgus pad

Extended the topcover medially in theshape of a valguspad will apply a forcevia the shoe upper tohelp createsupination moment.

A valgus pad can beadded under thetopcover. Mitchell, 10 Orthotic Modifications You Can

Perform in the Office Pod Mang Sept 2013

Vertical grinds to lateral RF posteffective control of supination +/- lateralEVA Fill• lateral sidewalls of these EVA

components are groundperpendicular to supportingsurface

• often combined with LateralFlange + Valgus FF postingextended to sulcus

Picture courtesy Jeff Root, Root Orthotic Labs

Medial heel skive and invertedreafoot

Pictures courtesy Jeff Root, Root Orthotic Labs

Heelstabilizer

Heel Skive

Heel skive

Heelstabilizer

Invertedheel

Kirby STJ rotational equilibrium

Pictures courtesy of Kevin Kirby DPM

Medial heel skive Korex modification

Photo courtesy of Larry Huppin DPM

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Medial heel skive with arch fill

Photo courtesy of Larry Huppin DPM

Lateral Column Overload

5th Met Cut-Out

• Shell materialremoved at distallateral aspect ofshell

• Used toaccommodatetailor’s bunion + 5th

MPJ lesions

Peroneal tendinopathy

Pictures courtesy of Kevin Kirby DPM

Lateral heel skive Korex modification

Photos courtesy of Larry Huppin DPM

Sometimes an footorthotic won’t do!47 ♀

Owns landscapecompany

Pain in right ankle forpast two years

Has been advised to gettriple arthrodesisBarefoot gait analysis

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Richie Articulated AFO

Richie Brace

Coronal CAT scan R Foot

Slices176 to180 outof 241

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Axial CAT scan R footSlices71 to74 outof 152

Sagittal CAT scan R foot

Cuboid Pad

The cuboid raise is a

very stabilizing and

under-used orthotic

modification for high arch

foot types and

for lateral ankle sprainers.

Jay D. Segel How to Approach Orthotic Modifications Pod Manag, Sept 2010

Increasedmetatarsal headpressuremodifications

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Extrinsic Plantar Met Raise

• Equal offloading from 1st to 5th MT heads by elevatingdistal end of shell

• Since no material is applied to the dorsal aspect ofthe shell, the shell maintains its original MLA profile

3mm EVA applied to plantar aspect ofdistal shell edge and tapered on the dorsalsurface

Intrinsic (within shell) Met Raise

• Leaves distal shell material full thicknesswith no tapering on dorsal aspect

• Creates drop off which will equally offload 1st

to 5th MT heads

• Effectiveness dependent on shell materialselection (not compatible with PRX)

• Maintains the MLA profile of the device

Metatarsal pad to off load painfulplantar metatarsal head

Picture courtesy of Kevin Kirby DPM

Capsulitis or plantar plate injury

Pictures courtesy of Kevin Kirby DPM

Distal End of Topcover Unglued

• Topcover is notlaminated at the distalend of the shell or toany extensions/bottomcovers

• Gives clinician abilityto modify or addcomponents such asmet pads/bars, lesionaccommodations,sulcus crests,neuroma pads

Top cover removed to allow formarking of plantar fibromas. Shellhas pre-glued as well as top cover

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Pre-glue topcovers and shell to allowlesion accommodations

Jobs that involve kneeling, stooping orsquatting require the proximal transferof pressure off of the metatarsal heads

• Minimum cast fill

• Positive cast inversion

• Flexible to semi-flexible polypropylene orEVA

• Non beveled anterior edge or Poronmetatarsal bar

• Deep parabola of anterior edge

• 3-6 mm neoprene or PPT/leather topcover with or without Poron forefootextension to sulcus

• Offloading of any overloaded met.head

1st MPJ/Ray modificationsMorton’s extension andReverse Morton’s extension

Mitchell, 10 Orthotic Modifications You Can Perform in the Office Pod Mang Sept 2013

Plantar fascia accommodation corkonlay

Mitchell, 10 Orthotic Modifications You Can Perform in the Office Pod Mang Sept 2013

Plantar fascial accommodation shellgrind

Photos courtesy of Larry Huppin DPM

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Marking the plantar fascia prior tocasting

Picture courtesy Jeff Root, Root Orthotic Labs

Cluffy™ wedge is helpful when othermethods of getting the 1st ray toplantarflex don’t appear to be effective

Clough Eight Methods of Improving Orthotic Outcomes Pod Mang Sept 2010

The valgus onlay by John Weed is agood in office modification to use to tryto salvage an orthosis that isn’tproviding enough valguscorrection/support in the forefoot

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Picture courtesy Jeff Root,Root Orthotic Labs

John Weed valgus onlay modificationwas used prior to the heel skivemodificationJohn Weed observed somepatients pronated excessivelyoff of their orthoses hetheorized these patients werenot controlled well enoughsince they were pronated atSTJ hence the MTJ wasunstable. He developed thevalgus inlay. The forefoot isdirected into valgus position.

“Richie wedgy” helps to offload theplantar fascia

Use 1/8 inch Korea and skive all three sides except lateral withheight point under mid shaft of the fifth metatarsal.

Pictures courtesy Doug Richie DPM

Sarrafarian Twisted Plate

Sarrafian SK Functional Characteristics of the Foot and Plantar Aponeurosis underTibiotalar Loading Foot & Ankle l 8,(1) 1987

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Valgus wedges reduce the strain onthe plantar fascia

Kogler D.F et alThe Influence of Medial and Lateral Placement of Orthotic Wedges on Loading of thePlantar Aponeurosis. An in Vitro Study J Bone Joint Surg Am, 1999 Oct 01;81(10):1403-13

Case of the Internal MetatarsalRocker

Combination of poly-carbon stiffenerand EVA rocker

Shoe volume modifications

Medial RF post only

• Reduces devicecontrol at heelstrike but maintainsmedial controlthrough midstance

• Reduces devicevolume, ofteneffective in designof dress devices

Lateral half of labstandard extrinsic RF postis removed along withstrikeplate

Posterior Heel Bumper

• 3mm to 6mm EVA wrappedaround heel cup of deviceto advance shell distallywithin shoe

• Full EVA thicknessmaintained at posterioraspect of heel and taperedto 0mm at medial andlateral edges

• Effective when dealing withshoe heel counters whichadvance the heel slightlyforward in the shoe

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Heel rim irritation modifications

Mitchell, 10 Orthotic Modifications You Can Perform in the Office Pod Mang Sept 2013

You can also grind the inside edge ofheel cup rim with dremel burr

Miscellaneous Modifications

Jobs that involve carrying, pushing andpulling loads on uneven surfacesrequire stabilization• High top boots provide most of

stabilization

• Steel shank if using ladders orshovels

• Orthotic device with flat posts,deeper heel cups and wider shell

• 3mm neoprene or Poron/leathertop cover

• Restaurant and retail workerssemi-flexible or flexible device witharch reinforcement along withpadded top cover

Jobs involving standing in place forlengthy periods require offloading fromcalcaneus and metatarsals heads

• Shell to be inversely flexible to thefirmness of the shoe and the surface

• Other factors: foot stiffness, amount ofequinus, weight and age

• Polypro, EVA or Plastazote #3

• Deep heel cups and wide shell withcongruent medial and lateral arch contour,

• Non bevelled anterior edge or met bar

• 3 to 6 mm neoprene or PPT/leather topcover

• In some cases a lower arch with moreshell flexibility is required but may notsuitable for exercise.

Top cover bunion accommodation

Pictures courtesy of Brian Cragg BSc DCh

Superthotic

• Direct milled shell,3mm puff topcoverto toes, agoflexbottom cover totoes

• Useful for devicesused in extremeconditions(temperature/dirt/debris exposure)

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Bottom covers help to stiffen top coversto allow for easy transfer in/out ofshoes

• Agoflex, vinyl, 1.5mm cork/puff bottom covers are effective

• Bottom covers also create sandwich effect at distal end of shellwhich improves component durability via improved lamination

Heel bursitis or heel spuraccommodation

Picture courtesy of Kevin Kirby DPM

A Simple Cure for Morton’s Neuralgia

Journal of the American Podiatric Medical Association Volume 90 • Number 2 • February 2000

Acknowledgments

Brian Cragg

Larry Huppin

Paul Paris

Doug Richie

Jeff Root

Lief Royle

Books by Kevin Kirby DPM thatdiscuss and illustrate orthoticmodificationsKirby KA: Foot and Lower Extremity Biomechanics: A Ten Year Collectionof Precision Intricast Newsletters. Precision Intricast, Inc., Payson, Arizona,1997.

Kirby KA: Foot and Lower Extremity Biomechanics II: Precision IntricastNewsletters, 1997-2002. Precision Intricast, Inc., Payson, Arizona, 2002.

Kirby KA: Foot and Lower Extremity Biomechanics III: Precision IntricastNewsletters, 2002-2008. Precision Intricast, Inc., Payson, AZ, 2009

Book 4 will be out this January

http://www.dpmlab.com/html/bookreview.html

In office modifications will increase patientsatisfaction and word of mouth referrals toyour practice.