This is part 19 of a series that should be read in order.
Key Points:
- What are H1, H2 and H3 orthotic devices?
Today I am going to finish my 19 part series on the Wild and Wonderful World of Orthotic Devices. I hope this lengthy discussion opened some treatment avenues you did not think about before. Next week, I will begin to discuss various injuries/pain syndromes, like Morton’s Neuroma or Posterior Tibial Tendonitis, and discuss the biomechanics of each that you should address. But, before I digress, let’s finish with Dr. Dananberg’s inspired devices.
H1 is now your basic Dananberg orthos as I see it:
- Soft plastic (sub-ortholen ™ or like material) with full frame fill
- 45 degree first ray cut out
- Kinetic Wedge (™) my version
- Rearfoot post if needed for alignment
Prescription for H1: (all prescriptions are my own)
- Balanced cast to Heel Vertical (only in B1)
- Lab discretion balancing B2
- 3 mm Sub-Ortholen (™) or 1/8th inch polypropylene
- 2 mm Higher Medial Arch
- 45 degree First Ray Cut Out
- Bevelled sub Hallux 1/8 inch wedge
- Dancer’s Padding
- 18 mm Heel Cup Heights
- Standard Width on Form
- Zero degree Extrinsic Rearfoot Post (only if needed for alignment)
- 1/8 inch Spenco full length
H2 improves on the off weighting of the first metatarsal with the following changes to H1 (you are freeing up the distal aspect of the medial column so you need to strengthen the proximal aspect of the medial column):
- Plastic the same
- 65 degree first cut out
- Version of Kinetic Wedge (™)
- Varus Alignment Correction with Higher Medial Arch, Medial Kirby Skive, or slight Inverted Technique (10-15 degrees)
- Definite Rearfoot Post
- Dancer’s Padding
Prescription for H2:
- Balanced cast to Heel Vertical (only in B1)
- Lab discretion balancing B2
- 3 mm Sub-Ortholen (™) or 1/8 inch polypropylene
- 2 mm Higher Medial Arch
- 65 degree First Ray Cut Out
- Bevelled sub Hallux 1/8 inch wedge
- Dancer’s Padding
- 18 mm Heel Cup Heights
- Standard Width on Form
- Zero degree Extrinsic Rearfoot Post
- 1/8 inch Spenco full length
- Varus Heel Correction for heel valgus (choose one—15 degrees Inverted Technique, 4 degree inverted pour or intrinsic wedge or 4 mm medial Kirby skive) Do not consider complete heel corrections like P orthoses
H3 improves the first metatarsal off weighting even more with the following changes to H2:
- Plastic the same
- Full First Ray Cut Out
- Kinetic Wedge (™) my version with increase in Hallux support over H1 and H2 to 3/16 inch thick)
- Varus Heel Correction (as in H2) of any heel valgus and application of Rear foot posting
- 2nd through 4th metatarsal support
- 2nd through 5th dancer’s padding full length
- Heel lift both sides 1/4 inch
Prescription for H3:
- Balanced cast to Heel Vertical (only in B1)
- Lab discretion balancing B2
- Varus Correction with any of these three: 15 degree Inverted Technique, 4 degree varus intrinsic wedge or pour, 4 mm medial Kirby Skive)
- 3 mm Sub-Ortholen (™)
- 2 mm Higher Medial Arch
- Full First Ray Cut Out
- Bevelled sub Hallux 3/16 inch wedge
- Dancer’s Padding
- 18 mm Heel Cup Heights
- Standard Width on Form
- Zero degree Extrinsic Rearfoot Post
- 1/8 inch Spenco full length
- 2 through 4 metatarsal pad
- 2 through 5 full length dancer’s padding
- 1/4 inch heel lift bilateral
You will get predictably more and more sagittal plane mobility with the progression of BH to H3. However, it is a balancing act of motion to the first MPJ, and loss of medial column support. Therefore, you have to experiment with assessing both functional hallux limitus and overall pronation tendencies. Whereas the basic idea is about forefoot mobility, and elimination of functional hallux limitus, I have used hybrids when dealing with combined abnormalities. For example, significant functional hallux limitus, low back pain and severe pronation. Here I may use a Pronation device (P) as my base, but add the first ray cut out, the bevelled hallux wedge, the dancer’s padding, and a heel lift.
This is one of my go-to orthotic devices for low back pain and big toe joint pain. For low back pain alone there are 4 choices of orthotic devices based on how the patient functions We have P orthotic devices for pronation control, S orthotic devices for supinatory control, H orthotic devices for better first MPJ motion at push off, and C orthotic devices for better shock absorption up the leg.
Review of all the Orthotic Types Being Presented
Corrective Orthotic Devices
↓
- Balancing (B): (B1 and B2)
- Pronators (P): BP, P1, P2, P3, P4, P5, and P6
- Supinators (S): BS, S1, S2, S3
- M/L Instability (M): BML, ML1, ML2, ML3, ML4, ML5, and ML6
- Shock Absorption (C): BC, C1/C2, C3/C4/C5, C6, and C7
- Sagittal Plane (H): BH, H1, H2, and H3
