Inside Insights On Orthotic Modifications For Sports

Clinical Editor: Timothy Dutra, DPM

Q: What is the importance of various modifications in your orthotic prescription for athletes?
Modifying the thickness of orthotics is important for Dr. Dutra, who notes that thicker orthotics are more rigid. Although one can add an arch fill to help facilitate better control for a heavier athlete, Dr. Dutra says the arch fill can make for a bulkier orthotic. He likes to use a wide orthotic plate and as deep a heel cup as possible to maximize motion control for the athlete.
In order to maximize control of the foot, Dr. Dutra says rearfoot posting is essential for most athletic shoes. He notes there are some sports exceptions, such as sprinting and volleyball, sports that don’t require athletes to be on their heels that much.
Adding a medial skive or inverted technique can be helpful when it comes to increasing control of pronation. Dr. Dutra frequently uses a medial skive of 2 to 4 mm to facilitate maximum control of pronation without adding bulk to the orthotic.
Dr. Dutra says employing forefoot extensions can help in offloading metatarsal heads and cushioning the transverse metatarsal arch area. They are especially helpful when athletes are participating in sport activities in which they are mainly using their forefoot and midfoot, according to Dr. Dutra. However, he says one should exercise caution when adding bulk in the toebox of the shoe, especially in shoes with cleats.
Dr. Pribut commonly modifies orthotics for sesamoid problems. He says incorporating a sesamoid pad, offloading the first metatarsal or using first ray cutaways can be beneficial. When treating metatarsal stress injuries, Dr. Pribut uses orthotic modifications to offload one or more metatarsals. He also notes that in the past few years he has come to use only intrinsic posting on orthotic devices.
Dr. Levine says the athlete’s foot mechanics combined with considerations of the demands of the specific sport will determine what kind of orthotic to prescribe. He recommends using more flexible devices for those who participate in court sports.

Q: What orthotic modifications can one use to control first ray pathology?
Dr. Pribut has found sesamoid accommodations or other first ray modifications, such as the kinetic wedge, reverse Morton’s or long or short first metatarsal cutaways, to be useful when dealing with first ray dilemmas ranging from turf toe and hallux limitus to sesamoid injuries. He also notes that some of these conditions may overlap or coexist in certain cases. If a patient complains of pain on the dorsum of the first metatarsal, Dr. Pribut says one should examine both the medial and lateral sesamoid bones for tenderness. If one observes a limitation of dorsiflexion and pain upon dorsiflexion, Dr. Pribut says the patient likely has a concomitant sesamoid pathology. Dr. Pribut rarely finds shoe modifications such as a rocker sole necessary to treat these problems.

When attempting to control first ray pathology, one should restrict pronation as well as the ground reactive force to the first metatarsal head, according to Dr. Dutra. He employs modifications like the Kirby medial skive and Blake inverted orthotic techniques to help control excessive pronation. If one leaves the anterior edge of the orthotic full-thickness, Dr. Dutra says it will act as a metatarsal bar and help offload the first metatarsal. He adds that this technique is also helpful in treating sesamoid pain along with a forefoot extension two to five and leaving a full thickness anterior edge on the orthotic.
One can control the first ray with a dancer’s pad, Morton’s extension, reverse Morton’s extension or a short or long first ray cutout, advises Dr. Levine. However, one should assess the foot mechanics before deciding on a modification and Dr. Levine says video gait analysis and pressure mapping are the best way to do that.

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