The previous four posts in this blog detailed some pearls in creating high quality, effective custom foot orthoses in a busy practice environment. The emphasis being on breaking down the process into easily manageable components to facilitate efficiency and decrease the possibility of errors. The physical exam findings and gait analysis findings should morph into the appropriate biomechanically based treatment plan. This includes, not only custom foot orthotics, but corresponding physical therapy and physical training, identifying weak or tight musculature, restricted joint motion, balance issues etc. Body morphology, shoe selection, intended activities and managing patient expectations are all important issues.
Once the practitioner and patient have agreed on the treatment plan to include functional foot orthotic devices, then biomechanical assessment commences. The orthotic build should be in the practitioners mind while performing this exam. Do you see asymmetry? Then you need to consider a heel lift for the short side, or more pronatory control on one side. Is there excessively lateral heel contact? Then the appropriate orthotic modification for that may be needed. Early heel off? During the non weight bearing exam, is there a limited subtalar joint range of motion on one side? Is the plantar fascia bowstrung? Are there digital contractures? These are just a few of easily observable conditions that all may be taken into account when building the orthotic device, there are many more. If you have a scribe or a competent assistant, then dictate your findings as you go along, or use a checklist or shorthand notations you can refer to later if needed. By now should have a firm grip on what the biomechanical needs of the patient are, and tailor a device for that patient.
Dr Blake likes the term “Gold Standard” for his favored orthotic device. I like the term,” my go-to device". Many, if not most patients, fall biomechanically, somewhere near the apex of the bell curve, as far as deformity goes. So the “my go-to-device” works well for many of them. A polypropylene frame, semi-rigid, a 12 mm heel cup with 1.5 mm heel padding, 3 mm arch lowering, a zero degree extrinsic rearfoot post, intrinsic forefoot correction to perpendicular to the rearfoot, full length extension and 3 mm Neoprene top cover. This is what I have worn for many years. I also often use this as a starting point for building an orthotic for my patients. The end product may be nowhere near this description, but sometimes it helps to start with something and add or subtract features as needed in that particular case. It is all about the decision making tree, and utilizing your time and expertise in the most effective and efficient manner possible to create optimum outcomes.
I would like to add a shameless plug here for the KevinRoot Medical website. It is your best reference source for all things functional orthotic. There is a complete list with detailed descriptions of all the modifications offered as well as the properties and usage of the various materials commonly used to build orthotics. Recommended build configurations for various pathologies, and many other circumstances, such as sports, dress shoe, military, pediatric and geriatric are all there and easily referenced. Good luck!
