Inside Insights On Orthotic Modifications For Sports

Clinical Editor: Timothy Dutra, DPM
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? A: 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. Q: What specific modifications should be considered when treating runners? A: Clinicians should initially ensure that their patients are wearing an appropriate running shoe. When treating patients who present with a difficult case of plantar fasciitis, Dr. Pribut says one should check their running shoes to see if they exhibit flexion stability and torsional stability. Drs. Dutra and Pribut recommend checking out the list of running shoes at, the Web site of the American Academy of Podiatric Sports Medicine, in order to determine which is appropriate for patients. Once the runner is wearing the right type of shoe, Dr. Levine says one can then design an orthotic that fits properly. Dr. Pribut uses a deep heel cup for most long-distance runners. He uses a full-length orthotic that is as thin as possible for sprinters. Dr. Pribut tailors his modifications to the basic devices he employs for the particular injury he is treating. Dr. Dutra likewise tailors his orthotic modifications based on the type of shoe or spike the athlete uses. Normally, he prefers to use a topcover to the toes that is made of a high-density material. He adds that it should be as thin as possible so it does not take up too much room in the toebox. Runners normally prefer a lightweight and flexible orthotic, according to Dr. Dutra. He adds that one may need to adjust the heel width of the orthotic in order to ensure a secure fit in the back of the shoe. In Dr. Dutra’s experience, many runners who are smaller and lighter prefer a graphite orthotic for fit and control of pronation. He says it is important for the running shoe to be stable in order to get the maximum control from the orthotic. Often, he waits to make additions or modifications to the orthotic after finding out the desired fit and control. Q: Do you use prefabricated or pre-custom orthotics? A: Although Dr.

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