Secrets To Fabricating Effective Custom Orthotics

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How To Prevent Heel Irritation When Using A Medial Heel Skive

The medial heel skive is an effective technique for providing greater control in an orthoses. It incorporates an interior varus wedge into the medial aspect of the heel cup of the orthosis. In order for this to be effective, the heel cup must be high enough to apply force medial to the subtalar joint axis.

As this technique becomes more popular, it becomes increasingly important to understand how to prescribe properly. Keep in mind that medial heel skive can lead to heel irritation at the edge of the orthosis in two instances: when the heel cup is too narrow and when the heel cup is too shallow.

Since the medial heel skive puts greater pressure on the heel fat pad, it widens the heel fat pad. Using a deeper heel cup can help contain the heel fat pad and prevent lateral edge irritation. Also make sure you provide caliper measurements of the heel width on weightbearing to your lab in order to ensure proper width in the orthoses.

Since a medial skive shifts the foot laterally, the heel cup must be deep enough to contain the heel and provide control without causing edge irritation. The minimum heel cup depth when using a medial heel skive is 14 mm. The heel cup depth should increase as the amount of skive increases. Therefore, you cannot use a medial skive with a dress orthoses since the heel cup depth is generally less than 14 mm.

When you are combining a medial skive with inversion, the slope you create can cause the foot to slide into the upper lateral edge of the heel cup. Using a deeper heel cup will prevent this problem. To avoid lateral heel cup edge irritation, use a 20-mm or 22-mm heel cup when the amount of skive plus the amount of inversion is greater than 5. To give you an example, 4mm skive plus two degrees of inversion = 6. Therefore, you would prescribe a 22-mm heel cup.

Direct milled polypropylene (as seen above) and vacuum formed polypropylene are “the most effective and versatile materials for functional orthoses for athletes,” notes Larry Huppin, DPM.
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Author(s): 
Guest Clinical Editor: Nicholas Romansky, DPM

Q: What do you do when the patient states the orthotic “feels like it is too far back”?
A:
Dr. Nunan checks the orthotic against the patient’s foot while the patient is weightbearing and nonweightbearing. Since the narrow width of the heel can displace the orthotic, Dr. Nunan examines how the orthotic sets in the shoe when the patient stands. He asks the patient to try to point out the precise area of pressure. If that fails, Dr. Nunan schedules an F-Scan evaluation to determine the cause of pressure.
When dispensing an orthotic, Dr. Romansky advises you to personally check the fit in stance and in the shoe. Ensure your patient is tying his or her laces tightly. Dr. Romansky says it’s a good idea to remind patients to tie their shoes with the foot flat on the floor and ensure the orthotic is seating itself properly in the shoe.
Dr. Romansky says you should send casts and orthotics back to the lab if necessary.

Q: What type of orthotic do you prescribe for a highly athletic individual who needs maximum control?
A:
Dr. Nunan says the prescription varies according to the sport, playing position and surface, and the shoes of the athlete. He often utilizes polypropylene and uses EVA or Korex to reinforce the arch. Dr. Huppin has also found success with vacuum formed and direct milled polypropylene, calling them “the most effective and versatile materials for functional orthoses for athletes.” He emphasizes that you can mold polypropylene to nearly any shape and it can be produced with almost any flexibility. He says the material “is nearly indestructible, has a long life span, and can be made to fit most any shoe.”
Dr. Huppin says he tends to avoid using carbon graphite or fiberglass devices for athletic activities since they tend to fatigue and crack under stress. However, Dr. Nunan notes some of the newer graphite composites are useful for shoes with little depth such as soccer shoes.
Dr. Nunan also has used multidensity EVA or leather and EVA combinations for athletes who want more lightweight devices. However, he cautions that these do not last as long.
Dr. Romansky says you can use graphite or polypropylene subortholene with a deep heel cup of 15 to 16 mm, depending on the type of sneaker or cleat of the athlete. According to Dr. Romansky, using a full-length orthotic helps decrease movement of the orthotic and adds forefoot cushioning.
Dr. Huppin says there is no panacea when it comes to orthotic materials for highly athletic individuals.
“There is no perfect orthosis material,” explains Dr. Huppin. “Every material has advantages and disadvantages. Given that, I find it is logical to use polypropylene for a majority of orthoses — including those designed for athletic activities — and graphite and fiberglass materials for smaller shoes and less stressful activities.”

Q: What topcovers do you use with the orthotic for hyperhidrosis and chronic recurrent blister formation?
A:
For hyperhidrosis, Dr. Romansky will use Drilex, padded fabric, Neolon, Spenco, R-lyte, Sky and EVA.
When dealing with this condition, Dr. Nunan will usually order orthotics with a Spenco or EVA topcover. All things being equal, Dr. Huppin says he would also use a material such as EVA that does not absorb moisture.
However, all the panelists agree that it is far more important to address the use of socks and provide direct treatment of the condition when dealing with hyperhidrosis.
One should take advantage of the various soaks, powders or lotions that are available for treating hyperhidrosis, notes Dr. Nunan. Dr. Huppin concurs and emphasizes the use of antiperspirants in treating the condition.
Dr. Nunan points out that most athletes wear cotton socks because of availability and cost. When treating patients who have chronic blisters and hyperhidrosis, he recommends they wear athletic socks, usually those of an acrylic blend. Other socks that may be effective include double layer socks or socks with extra padding. Drs. Huppin and Nunan say it is important to emphasize socks that wick the moisture away from the skin and to the outer layers.
Dr. Romansky adds that excessive wear of socks can be a problem with blisters. He also cites insoles not being removed from shoes and laces being tied too tightly during an athletic event.

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