Any specialist who prescribed custom orthotic devices must know how to adjust when the patient complains of arch irritation.
Arch irritation may not be as simple as the "arch being too high", but that is the general rule out there. Definitely, you can request a warranty remake from the lab. Did you know we [KevinRoot] offer warranty remakes without sending back the orthoses? Or your office or home can have a dremel-like or sanding disc to file the arch down. However, for some patients, feeling excess pressure in the arch means other things: the need for a plantar fascial groove, the need to raise the arch, or the need to varus tilt the heel.
Image of the typical alignment of a plantar fascial groove along the first metatarsal shaft from in front of the heel.
Plantar Fascia groove seen from the bottom of the foot
The main message of this post is that shaving down the bulk of the medial arch does affect the stability of the orthotic device, and although necessary at times, may be actually going in the wrong direction. Try definitely to identify the exact point of the arch irritation: one spot, general discomfort, medial edge, or off the edge and more lateral. Ask the patient if they feel the discomfort in the shoe as same as out of the shoe. Is it in the "0-2" pain range, which they probably will get used to during the break in process, or higher that should be adjusted today. As they walk up and down the hallway, does the sensation feel better or is it magnifying?
Now it is time to watch the patient walk, perhaps after a minor initial adjustment. Do you like how they are walking? Are they stable, or not? Many cases of arch pain are related to not controlling pronation as well as needed. The patients continue to pronate with resultant medial arch collapse into something hard. Here lowering the arch will make the pronation worse, and sacrifice stability. Adding some varus heel and/or forefoot wedging will definitely help with the pronation and arch discomfort. Of course, this all may have to wait a visit if you deem that their shoes you are fitting the orthotic devices into are not stable enough and need replacement before you go adjusting the orthoses.
I will always stress to patients that I want stability, and compromises like lowering the arch may sacrifice some of that stability. You can change the loading on the arch with another forefoot pad distal to the plastic, or a heel lift, or a slight varus wedge tilt (as above), or skipping the lacing above the arch called "sweet spot lacing". If I have made a modest arch adjustment, but the patient still seems annoyed, this is my checklist: (A) Shoes Appropriate?, (B) Stability with Orthosis?, (C) Add metatarsal pads and/or varus wedges if too much pronation, (D) Add Heel lift (both sides of course) and/or forefoot padding if good stability, and (E) Does it seem to be the plantar fascial bowstringing alone that is being irritated?
Dr Richard Dempsey added some more brilliant thoughts that are worth sharing. Arch irritation can simply be caused by equinus forces forcing the foot on the orthotic plate. This is a great time to check equinus and place the patients on a good stretching program. When you add a heel lift, you change the weight distribution on the orthotic device. Sometimes the heel lift places more pressure on the arch and sometimes it shifts it off the arch. This is a good modalities to try if the patient has arch pain. The third comment by Dr Dempsey is also important. Flexor contractures can cause arch irritation, and not normally captured in the cast. Orthotic modifications are the only way to rectify this pressure after the patient walks around awhile and can give you feedback.
Arch irritation, complained by the patient, should be a thoughtful process to maintain as much stability as possible.
If you need to request a warranty remake, send pictures and descriptions to your client rep and the specifics to adjust your prescribed orthoses. We are on your side to achieve the best outcome for your patients.
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