Adjusting Orthoses: Simple Solutions To Common Complaints

Larry Huppin, DPM

When Orthotic Adjustments Are Needed

There are several general categories that require one to make an adjustment to an orthosis.

   Direct discomfort. In this situation, patients find that the orthosis causes pain when they wear the devices. This occurs commonly in the arch (for example, the arch feels too high) but can occur at any point where the orthosis makes contact with the foot.

   Continued symptoms. In these cases, the patient may find the orthosis comfortable but continues to have symptoms. If there are orthotic adjustments that might further reduce symptoms, then an orthosis adjustment is called for.

   New symptoms. In this situation, patients may not notice any direct irritation from the orthoses and they may have had resolution of their original symptoms, but they now have developed new symptoms. For example, patients may develop knee pain when they wear a new orthosis they received for treatment of plantar fasciitis.

   Shoe fit. Either due to poor shoe choices or poor communication, patients may find that their orthoses will not fit in the shoes they plan to wear.

How To Make Adjustments For Direct Discomfort

Arch irritation is the most common direct discomfort issue that requires adjustment and these adjustments may be required more often when orthotic prescriptions are based on evidence in the literature. Studies over the past decades have shown that for many of the most common pathologies for which we prescribe orthotics, orthoses that conform closer to the arch of the foot are more effective than those that gap from the arch of the foot. These include studies that give guidance to how one should write orthotic prescriptions for the treatment of plantar fasciitis, metatarsalgia and hallux limitus.

   In a 1996 cadaveric study, researchers demonstrated that orthoses that conform closely to the arch of the foot more effectively reduce plantar fascia tension.1

   Another study focused on the effect of a total contact insert and a metatarsal pad on metatarsal head peak plantar pressures and pressure-time integrals.2 The study authors concluded that the total contact insert and metatarsal pad led to substantial and additive pressure decreases under the metatarsal heads. By increasing the contact area of weightbearing forces, the total contact insert lowers excessive pressures at the metatarsal heads.

   Roukis and colleagues concluded that preventing first ray plantarflexion led to hallux limitus.3 The authors also found that when the first ray could plantarflex, there was an increase in available first metatarsophalangeal joint (MPJ) dorsiflexion. This study shows that orthotic devices that conform close to the arch, thus preventing first ray dorsiflexion, will enhance windlass function.

   Harradine found that increasing heel eversion, which dorsiflexes the first ray as the medial forefoot is forced into the supporting surface, reduces the first MPJ’s available dorsiflexion.4

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