Pertinent Pearls On Orthotic Adjustments And Casting

   Given the nuances of making adjustments to orthotic prescriptions, our expert panelists discuss their approaches in using adjustments such as first ray cutouts and metatarsal pads, and the tools necessary for making modifications. They also discuss which adjustments they will make themselves and which ones they will send out to an orthotics lab. Without further delay, here is what they had to say.    Q: How do you incorporate footwear when determining appropriate orthotic prescriptions?    A: Ideally, Howard Horowitz, DPM, says one should tailor the shoe and orthotic to the patient’s pathology. For example, if the patient has hallux limitus, the shoe should have a stiff sole with a lower heel. Dr. Horowitz does not make many orthotics for high-heeled shoes. Since an orthotic’s primary function is controlling heel to toe gait, Dr. Horowitz says the benefit of an orthotic in a high-heeled shoe is questionable.    When prescribing an orthotic, DPMs must know the type of shoes the patient expects to wear, according to Douglas Milch, DPM. For a woman who wears a dress shoe, he prescribes a thinner graphite material and will probably leave out an extrinsic rearfoot post. Dr. Milch would use a narrow grind width and low heel cup height. Dr. Milch notes that shoes with a strong heel counter and sufficient depth can best house the orthotics and optimize functional results.    Dr. Horowitz prefers using an extrinsic rearfoot post in order to control the rearfoot as much as possible immediately after heel strike. With a dress flat or short dress heel, he will send both the shoe and cast to the orthotic lab for a better fit for the rearfoot post. Dr. Horowitz notes that grinding the thickness of the rear post to “almost a hole in the heel” will typically permit a successful fit for the device. Patients should always take orthotics to the store when purchasing new shoes, according to Dr. Horowitz.     “I try to impress on the patient the notion that while the orthotic supports and helps guide the foot, the shoe supports the foot over the orthotic,” emphasizes Dr. Horowitz.    Bruce Williams, DPM, gives patients handouts on shoe suggestions. These handouts include one from Mark Reeves, DPM, and a handout from the American Academy of Podiatric Sports Medicine (AAPSM), which demonstrates how lacing techniques can aid in shoe fit. Dr. Williams will point out to patients the pros and cons of different shoes, and how orthotics will function better in shoes with motion control. Dr. Williams has recently started adding pedorthic modifications to shoes on a limited basis but notes that he sends most of those modifications, such as heel lifts on outersoles or rocker bottom soles, out to a pedorthist or the orthotic lab.     “If I had my way, everyone would be wearing a running shoe or an SAS walking shoe because most of the time when we prescribe orthotics, we are attempting to control foot motion,” opines Dr. Milch. “You can make the greatest orthotic in the world. However, if patients either cannot fit it into the shoe or put the orthotic in a flimsy shoe, the results are compromised at best.”    Q: What are the most common adjustments you make to orthotic devices?    A: Dr. Williams adds first ray cutouts of various sizes that often differ from the right foot to the left and also incorporates heel lifts and posts. He adds PPT™ (Langer) under the topcovers of cutouts. He uses first metatarsal grooves, a thinning of the orthotic shell or a trough in an ethylene vinyl acetate (EVA) device. In heel cups, Dr. Williams will add medial or lateral Kirby skives, utilizing 1/16, 1/8 or 1/4 inch of Korex or EVA if needed after construction of the device.     “There is little that can be done by a lab that persistent podiatrists cannot mimic themselves,” asserts Dr. Williams. “It may not always look as pretty but it will almost always function just the same.”    Dr. Horowitz has used an increased number of first metatarsal head and first ray cutouts to increase the proper function of the first ray.

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