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 prescriptions for orthoses Requires improved troubleshooting skills Lawrence Z. Huppin, DPM Metatarsalgia Hastings 2003. Hsi. 2005 Holmes 1990 Chang 1994 Arthritis Chalmers, 2000 Powell, 2005 Thompson 1992 Slattery, 2001 Plantar Fasciitis Kogler, 1999 Lynch, 1998 Tarsal Tunnel Syndrome Kinoshita, 2004 Trepman, 2000 Labib, 2004 Hallux Limitus Scherer, 2006 Mankay, 1996 Roukis, 1996 Whitaker, 2003 Munteanu, 2006 Knee Pain Saxena 2003 Stackhouse 2004 What Do We Lose When We Don t Modify Our Own Orthoses? Total Contact Rigid Orthoses Metatarsalgia Total Contact Orthosis reduces excessive pressures at the metatarsal heads by increasing the contact area of weight-bearing forces. Mueller, 2006 Semi-rigid orthoses had significant effect on pain. Soft orthoses did not show a significant effect on pain, nor did shoes alone. Chalmers, 2000 Pes Cavus TCO decreased plantar pressure and pain, Burns, 2006 Tarsal Tunnel Syndrome Arch collapse increases tarsal tunnel symptoms, Trepman 2000 Hallux Limitus Lack of first ray plantarflexion limits hallux dorsiflexion, Roukis 1996 Total Contact Rigid Orthoses Hallux Limitus Lack of first ray plantarflexion limits hallux dorsiflexion, Roukis 1996 Minimum fill orthoses Inverted casts 3 1
Evidence Based Orthotic Therapy Improved Clinical Outcomes Tend to be More Aggressive Higher arches Wider and Deeper More modifications Met pads, RME Evidence Based Orthotic Therapy Greater Need for Adjustment Choices Prescribe less effective, no-adjustment orthoses Lower arches Generic prescriptions Develop troubleshooting / modifications skill Why Are Orthoses Less Effective Lack of skill or desire to troubleshoot Demand for no adjustment necessary orthosis from lab Lab overfills medial arch Rarely a complaint regarding orthosis irritation Rarely achieve optimum clinical outcomes Did Podiatry Miss the XXX Jason Krauss Orthotic Complications Direct Discomfort Continued Symptoms New Symptoms Inability to Use Devices Shoe Fit 2
Prescribing for Modifying Polypropylene > Carbon Fiber Wider and Deeper Covers glued posterior No bottom covers Patient Education Patient Education for Modifying Arch Height May be a bit high in arch Orthosis Size May be too wide Unglued cover or No cover Comfort guarantee Materials and Equipment Grinder Polishing Grinder Ticro Cone JMS or your orthotic lab 3
Glue Hood or Filter Fume Buster www.atlasortho.com Safe Glue Solvent Kirby Pepper Jar Technique www.orange-sol.com/household/ Materials Needed Materials: Cover EVA Soft (1/8 ) Wedges / Accom EVA Firm (1/8 ) Korex (1/4 and 1/8 ) Cushion Poron (1/8 and 1/16 ) Self Adherent Posting Wedges www.orthofeet.com/ 4
Modifications Modifications for Comfort Modifications for Comfort Modifications for Function Modifications for Fit Arch Irritation Plantar Fascia Medial Edge Irritation Lateral Edge Irritation Heel Irritation Prominences Arch Irritation Increase Arch Flexibility Add Plantar Fascial Groove Grind for Flexibility Arch Pain Localized Arch Pain Plantar Fascial Irritation Add Plantar Fascial Groove 5
Edge Irritation Soft Medial Flange EVA to medial arch with cover Medial Edge Irritation Lateral Edge Irritation Posterior Heel Edge Irritation M L M L L M Top Bottom Top - Finished Soft Medial Flange Indications: Medial edge irritation Orthoses too narrow PTTD, os navicularis, etc Soft Lateral Flange Modification: EVA to lateral aspect of orthotic Medial Lateral 6
Soft Lateral Flange Posterior Heel Irritation Indications: Lateral edge irritation Prominent styloid Intolerance to hard flange &/or not enough width in shoe for hard lateral flange Slipping off orthotic laterally Heel cup too narrow? Orthosis too far anterior in shoe? Prominences Grind Horseshoe Pad Allow Orthosis to Slide back in shoe Lower Heel Cup Lift Orthosis into Wider Portion of Shoe 7
Cushioned Heels Modification: Adding 1/8 or 1/4 PPT to heel Cushioned Heels Indication(s): Fat pad atrophy Calcaneal apophysitis Calceanocuboid Medial longitudinal arch irritation Modifications to Improve Function Medial Wedging Excessive STJ Pronation Lateral Wedging Lateral Ankle Instability Peroneal Tendonitis Increase Arch Height 1 st MPJ / Fhl Mofications (RME, ME) Hallux Rigidus Hallux Valgus Plantar Fasciiits Varus (medial) Wedging MTSS Posterior Tibial Tendonitis Lateral knee DJD (I.e. coxa vara/ genu valgum) Medially Deviated Subtalar Joint Axis; Patient still symptomatic Need extra control 8
Evidence for Varus Wedging in Medial Tibial Stress Syndrome Increased STJ pronation contributes to MTSS Messier SP, Pittala KA. Etiologic factors associated with selected running injuries. Med Sci Sports Exerc 1988; 20(5):501-5. Craig DI. Medial tibial stress syndrome: evidence-based prevention. J Athl Train 2008; 43(3):316-18. Viitsalo JT, Kvist M. Some biomechanical aspects of the foot and ankle in athletes with and without shin splints. Am J Sports Med 1983; 11(3):125-130. Krivickas LS. Anatomical factors associated with overuse sports injuries. Sports Med 1997; 24(2):132-46. Varus Wedging Reduces Pronatory Torque Kirby. Rotational Equilibrium Around the STJ Axis In-office varus wedge modifications Medial Heel Skive Medial Heel Wedge Runners Wedge Adding a Medial Heel Skive Use Korex or EVA Lateral Medial Heel Wedge More aggressive than medial skive Indications: Posterior Tibial Tendonitis or PTTD Lateral knee DJD (I.e. coxa vara/ genu valgum) Medially Deviated Subtalar Joint Axis; (moderate to severe) Patient still symptomatic Need extra control Medial Medial Heel Wedge Korex or EVA to medial heel post and forefoot Medial Heel Wedge Medial OR Lateral M L 9
Runners Wedges - Indications Running Pathology Orthoses offer good control with daily activities but extra control needed for running MTSS, PTTD, PT tendonitis, etc. Varus Wedges / Runner s Wedges Full length varus wedge on insole: 1/8 korex = 3.5 degrees of inversion 1/4 korex = 7 degrees correction Valgus (Lateral) Wedging Indications: Medial knee pain Medial knee DJD Peroneal Tendonitis Evidence for Laterally Wedged Orthoses in Medial compartment OA Compared Foot orthosis with lateral wedge to orthosis w/o wedge: Significantly reduced knee pain as compared to patients who wore the same orthoses without the lateral wedge Butler: The effect of a subject-specific amount of lateral wedge on knee mechanics in patients with medial knee osteoarthritis. J Orthop Res. 2007 Comparison of lateral wedged insole with custom foot orthoses that incorporated a lateral wedge Orthoses with the wedge was superior in reducing pain in patients with mild or moderate knee OA. Rubin: Use of laterally wedged custom foot orthoses to reduce pain associated with medial knee osteoarthritis: a preliminary investigation. 2005 10
In-office valgus wedge modifications Lateral Heel Skive Lateral Heel Wedge Lateral Skive Add Korex or EVA to inside of lateral heel Medial Lateral Lateral Heel Wedge More aggressive than lateral heel skive Add Korex or EVA to lateral heel post and forefoot Increase Arch Height Indications: Orthosis Gaps from Arch Arch Collapse Evidence: Metatarsalgia, Diabetic ulcer, Cavus, Tarsal tunnel Medial Lateral 11
Forefoot Extensions RME ME Valgus Extension Varus Extension Evidence for valgus forefoot extensions in treating plantar fasciitis Plantar fascial strain decreases with valgus forefoot wedge Kogler, JBJS1999 Modifications for Fit Orthotic too thick slips in heel Orthotic Too Thick ; Heel Slips Modifications: Flat grind heel &/or heel hole orthotic Increase Toebox Room Grind to Fit 12
Take Home Skill at in-office orthotic modifications means better clinical outcomes Podiatry s Choice: Evidence Based Orthotic Therapy More aggressive orthoses Need for troubleshooting skills A niche for podiatry as the experts in orthotic therapy No adjustment orthoses Accept reduced clinical outcomes Accept that shoe stores, chiropractors and others can do this as well as you Thank You 13