Treating FHL: Why It's Essential For Orthotic Success

Improved Outcomes Spark Boost In Referrals
“Recognizing Fhl has permitted an expansion of practice through successful treatment of postural complexes which, prior to Fhl identification, had fewer successful responses to therapy,” says Glenn A. Ocker, DPM, MS.
Dr. Ocker emphasizes that many patients who had previously unsuccessful orthotic therapy responded favorably when he identified Fhl and employed prescription orthotics with Kinetic Wedge therapy. This treatment has increased overall successful outcomes and often provides quicker response times to therapy, according to Dr. Ocker. As a result of the improved outcomes he has been able to achieve with Kinetic Wedge therapy, Dr. Ocker says he has seen an increase in referrals for lower extremity evaluations for spinal symptom complexes.
“It is my opinion now that there are few conditions which would not benefit from a timely plantarflexion of the first metatarsal and resultant midtarsal joint stabilization,” says Dr. Ocker.

Q: What has been your patients’ reaction to this treatment, particularly in those who have had a more standard approach to orthotic care?
A: One of Dr. Williams’ patients is a professional basketball player who had several failures with traditional orthotic therapy. All his orthotics posted him into varus.
“The problem was that in stance and during gait, he never, and I do mean never, put any weight under his first metatarsal head,” recalls Dr. Williams. “I use the F-scan system on certain patients for gait analysis. When I saw the pressure distribution for this patient, I was amazed. He had all of his weight lateral. He never put any weight under the first met.”
When Dr. Williams made the basketball player a temporary orthotic and used a first ray cutout, the patient immediately walked better and he finally had pressure under the first metahead. He valgus posted the patient an extra four degrees and adjusted for his LLD. “He’s been playing great all year,” says Dr. Williams.
Dr. Ocker says his patients are often “remarkably impressed” that one practitioner’s orthotics offer such a dramatic improvement over another’s orthotics.
“This has proved most startling and informative,” says Curryer. “Patients who have had orthotics from myself or others based on ‘Rootian’ principals or just arch supports tend to notice and comment on a sensation that their feet feel ‘free.’ They do not feel confined and almost always feel a positive postural benefit.”
A number of patients have come to Curryer’s office with foot orthoses from other providers that have not resolved their symptoms or have created other problems. Invariably, he has added an Fhl accommodation and a lateral forefoot wedge to the existing device. Six weeks later, these patients have shown marked improvement in symptoms and orthoses wear patterns, according to Curryer.
Given these successes, Curryer has also changed non-responsive fifth MTPJ diabetic ulcer patients to this approach as opposed to using a conventional arch support, varus-posted device. These lesions, which historically were difficult to maintain, healed, resolved quickly and remained healed when Curryer applied SPF principles to their foot orthoses.

Be Aware of These Post-Therapy Outcomes
Generally, you may find that patients notice some initial strain in their hip flexors, possibly due to the orthoses requiring the leg to extend fully in gait. Patients often experience some lower back stiffness initially but it resolves well with physiotherapy and a few weeks time, points out Curryer. Dorsal first MTPJ pain is rare, but if it does occur, Curryer says you can resolve the problem via manipulation and, if necessary, a local steroid injection.
On many occasions, Curryer’s patients with foot or leg symptoms will return to him, saying they have noticed a decrease in previous back, neck or other postural complaints that they did not mention upon their initial visits to him. He says he did not notice this consistent patient response when he utilized conventional biomechanical approaches.

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