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. Dr. Huppin is an Adjunct Associate Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt College. He is also the Medical Director for ProLab Orthotics. Dr. Huppin can be reached at firstname.lastname@example.org. Dr. Nunan is a Fellow and Past President of the American Academy of Podiatric Sports Medicine.