PROBLEMS AND ORTHOTIC SOLUTIONS. Problem/Issue Underlying treatment goal Solution Pes Cavus foot

Size: px

Start display at page:

Download "PROBLEMS AND ORTHOTIC SOLUTIONS. Problem/Issue Underlying treatment goal Solution Pes Cavus foot"

Stephen Willis
5 years ago
Views:

1 PROBLEMS AND ORTHOTIC SOLUTIONS Problem/Issue Underlying treatment goal Solution Pes Cavus foot Usually also a supinated foot Rigid high arched foot with poor shock absorption and cushioning. Often roll out laterally (if supinated). Needs a device with a high arch to give total contact and spread forces. Also, want some shock absorption. Pes Planus foot Usually also a pronated foot Rheumatoid Arthritis Osteoarthritis (can occur in any joint) Charcot Marie Tooth (CMT) Functional Hallux Limitus Hallux Limitus/Rigidus Hallux Adbucto Valgus This foot is usually very flexible and needs the assisting control of a rigid or semi rigid orthotic. Have to watch for irritating the foot, so topcovers are important discussion. Inflammatory disease causing foot to change shapes and develop sensitive plantar prominences. Inflammation in joints causes pain when those joints move. Solution is to stabilize the joints and keep them from moving. Leg muscles atrophy and creates a rigid high-arched foot and lateral rolling over. Great toe (hallux) can dorsiflex at the MTP joint if not weightbearing, but cannot on weightbearing. This means it is not a bony problem, but a muscle/joint problem. We have to unlock the joint, allowing the head of the first met bone to plantarflex so that the hallux can dorsiflex. Do this by allowing the MTP joint to drop. Great toe has very limited (limitus) or no (rigidus) dorsiflexion at the MTP joint under any circumstances. Flexible collapsed foot has added extra pressure to 1 st MTP. This joint has become dislocated and the toes --3D can go high in arch, but forgives. --Softer orthotics can also work. --Possibly some lateral wedging. --Rigid device --Semi rigid device --Good arch support, but depending on foot, you may have to scale back --Accommodative orthosis with arthritic trilam topcover. Allows support with cushioning, and easy for Store C.Ped to adjust. --Support and stabilize the joint usually with a rigid or semirigid shell. Try to limit motion. --Cushion the foot/area --Remove pressure from painful areas (cutouts/unloads). --Deep heel cups --Lateral flange/clip/wedge. --Denton modification (extend post laterally). --Shock absorbent cover --Kinetic Wedge --Reverse Morton s extension --Provide support under hallux, usually with rigid morton s extension/turf toe plate --can be cut into shell or added. with good arch support. Trying to move pressure from the 1 st MTP back onto the arch. Unload any

2 (aka Hallux Valgus and sometimes mistaken for a bunion) Metatarsalgia Morton s Neuroma Morton s Toe Sesamoiditis have migrated. Excessive pain in the met heads from pressure. Goal is to move the pressure off of the met heads onto the arch and shafts of mets Trapped nerve in the space between toes usually 3 rd and 4 th. Goal is to lift and separate the heads to relieve pressure Short hypermobile great toe next to longer second toe. Great toe does not bear its own weight (because short and hypermobile) so second met gets excess pressure and is usually very painful. Painful area under sesamoid bones under 1 st MTP sensitive areas.. --Met Pad (2-4) --Met Bar (1-5) --Unload under met heads --Met Pad (2-4) --Neuroma Pad (3-4) --Flexible Morton s Extension under the great toe. This will engage the first ray and make it carry its load. It will also work to unload the painful second.. --Kinetic wedge (to create unload under painful area). --Can also extend shell and do a first ray cutout --Can also try Reverse Morton s and/or met pad. Achilles Tendinitis Pain in Achilles Tendon --Add heel lift to reduce strain on Achilles. Will be ground off as healing occurs. Might want to make separate from device. --Good rearfoot control through deeper heel cups to limit rearfoot motion Posterior Tibial Tendon Dysfunction Plantar Fasciitis Collapse of Post Tib tendon, causing foot to collapse. Can be rigid or flexible. Tear and strain on the plantar fascia on bottom of foot. Three goals for treatment: support arch, cushion foot, lift heel --If flexible, need a Blake Highly Inverted. --If rigid, then a 3D with unload for navicular and a medial stabilizer in shoe to accommodate the protruding navicular --A supportive orthotic with good arch support is the best place to start. Best to use a semi rigid construction for cushion, and the orthotic itself will lift the heel. --Some doctors like a donut in the heel, especially if they think a spur is causing problems. Diabetic Foot Management 2 goals manage the biomechanics of the foot while protecting the soft tissue --Start with a supportive orthotic we start with 3D and only go to accommodative if foot is really collapsed. Use diabetic topcovers. Plastazote will break down. If the skin is healthy, use Spenco over PPT. Calcaneal Apophysitis Heel pain in growing children caused (rigid or semi rigid)

3 Tarsal Tunnel Syndrome Shin Splints Chondromalacia Patella Lateral Knee Pain Medial Knee Pain by strain on bone plates. Goal is to make the foot a rigid lever and reduce strain on the Achilles. Want shallower heel cups to avoid irritating the spot. Pain on medial side of calcaneus where nerves and veins pass under sustentaculum tali. Excessive pronation can cause it. Caused by tearing of retinaculum in leg due to excessive pronation. Part of Patello Femoral Pain Syndrome. Symptoms of anterior or posterior knee pain exacerbated by stairs and frequently occur upon standing after prolonged sitting. Trying to limit STJ pronation and therefore leg rotation. Also limit midtarsal joint collapse. Knee joint collapsing on lateral side and pinching. Knee joint collapsing on medial side and pinching. --Wider cut to make orthotic more sturdy. --Shallower heel cup. --Mild heel lift to reduce strain on Achilles. to limit pronation. --Wider and more rigid will help. --Mild inverted orthotic will work well. - that limits pronation. --Inverteds or skives help --Wider device for more control. --Medial wedge on orthotic to open up the lateral side of the knee joint. --Lateral wedge on orthotic to open up the medial side of the knee joint.

4 Cross Reference of Our Options Name Description When Used Met Unload Creates a pocket for the met head to rest in and remove ground pressure When there is a painful met head Regular 1/8 Nickelplast Softer 1/8 PPT or Puff Navicular Unload Creates a pocket for the navicular to rest in and remove ground pressure When there is a painful navicular (arch bone) Change made on Positive / cushion with 1/8 Heel Unload Heel Cup Depth Creates a pocket for the bottom of the heel (calcaneus) to rest in and remove ground pressure The deeper the heel cup, the more control over the foot the heel cannot move as much and the foot cannot pronate as much. However, to much heel cup can affect shoe fit and can be uncomfortable. Intrinsic Met Pad Creates a very mild met pad under 2-4. Extrinsic Met Pad Extrinsic Met Bar Arch Height Grind Width Creates a pronounced met pad under 2-4. Creates a pronounced met bar under 1-5. The amount of the arch support will affect how much control the orthotic provides for the arch of the foot. Wider orthotics provide more control and are more rigid, but are harder to fit into shoes, especially dressier shoes. Narrower orthotics are more flexible and forgiving, and fit into thinner shoes. PPT When there is a painful calcaneus 1/8 PPT horseshoe pad Our standard heel cup depth provides good control. We increase it when we want more calcaneal control. 14 Reg 16 Deep 18 Deeper To move pressure off of the met heads and onto the met shafts which are stronger. Correction on the positive( Padding window) To move pressure off of the met heads and onto the met shafts which are stronger. #2 Gray Pre-fab met pad To move pressure off of the met heads and onto the met shafts which are stronger. This provides maximum relief. PPT Pre-fab met bar Increasing the arch height provides more control over the foot. This is generally seen as less comfortable, yet more effective. Decreasing the arch height allows more movement and is seen as more comfortable, yet less effective. Correction on the positive We generally cut the orthotic to fit the foot. We can increase width to increase control but this only goes so far because you have to be able to get the device in the shoe. It is more common for us to cut an orthotic narrower in order to get it to fit in a

5 Turf Toe Option Morton s Extension (soft) Reverse Morton s Extension (soft) Kinetic Wedge Shell Medial Flange Shell Lateral Flange/Clip Denton Creates a rigid extension under the hallux, either by cutting it into the shell or adding a carbon plate. Limits motion of the first ray. A small ramp of material put under the great toe, distal to the shell. A forefoot unload that has material under 2-5, but cuts it out under the hallux. A forefoot unload that has a cutout just under the 1 st MTP joint opening to the medial side of the orthosis. An increase in the heel cup on just the medial side An increase in the heel cup on just the lateral side A fill under the orthotic along the lateral border of the orthotic. It dressier shoe. Based on a relationship to the heel width reg 1/2" wider than heel Narrow 1/4" wider than heel Wide 3/4" wider than heel This helps with arthritis in the first ray, because if the joint can t bend it won t be painful. Carbon plate w mortons Stiffner --Primary use is for Morton s Toe (short hypermobile first toe which yields a painful second met head). --Secondary use sometimes under hallux limitus or rigidus if trying to provide some protection and support for hallux. 1/8" nickleplast --Useful for plantar flexed first ray creates a space for it to drop. --Useful for functional hallux limitus. --Useful for sesamoiditis (see Kinetic Wedge). Regular 1/8" nickleplast Heavier Pt's Pro XP II --Useful for sesamoiditis. --Useful for functional hallux limitus 1/8 Nickleplast in a multi layer or 1/4" EVA like a ff post w/cut out for 1st met head --Useful to provide more medial control and prevent pronation and collapse. Correction to positive, should be ground with a wide high sweeping medial edge --Useful to provide more lateral control and prevent supination. A clip is a shorter flange and provide less control, but is more comfortable and easier to get into shoes. Used in combination with a deeper heel cup, Clip- 5mm superior lateral edge ending proximal to the 5th met base. resembles a fish dorsal fin. Flange- 5mm superior lateral edge ending proximal to the 5th met head. Provides lateral support without wedging. Acts like a buttress.

6 Wedges Lifts Kirby Skive Blake Highly Inverted extends the heel post all the way up to the distal end of the shell. this correction is great for anyone involved in lateral motion sports. Depending on placement, will increase control on the medial or lateral side Added under the heel to provide extra heel height. A cast correction to provide extra medial force to the calcaneus A cast correction to provide extra medial force to the calcaneus over a wider surface area. Pro xp II filling the gap from the distal aspect of the rearfoot post to the distal edge of the shell on the lateral 1/3 of the shell. To control pronation or supination 3 degrees or less 1/8 nickleplast. 4 degrees or more firm crepe --Can be used temporarily for Achilles Tendinitis to take strain of the Achilles. --Can be used permanently for LLD. Crepe EVA --Useful to provide more medical control Correction to positive --Useful to provide more medial control especially for Post Tib Tendinitis. Correction to positive

Why Are We Here? Total Contact Rigid Orthoses

Why Are We Here? Total Contact Rigid Orthoses Evidence Based Approach to: Orthotic Troubleshooting and In-office Modifications American College of Foot and Ankle Orthopedics and Medicine Why Are We Here? Evidence Based Orthotic Therapy More effective