Pertinent Pearls On Orthotic Adjustments And Casting

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Here is a polypropylene functional foot orthosis with an EVA rearfoot post. Howard Horowitz, DPM, prefers using an extrinsic rearfoot post in order to help control the rearfoot as much as possible immediately after heel strike. (Photo courtesy of Alona Ka
Although Dr. Horowitz acknowledges that plaster casting can be messy, he believes it is less expensive than other casting methods and more accurate. (Photo courtesy of Lawrence Huppin, DPM)
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   Q: What is your opinion on plaster casting for orthotic devices? Do you always cast the same way or do you vary your approach depending upon the foot type? Do you scan the foot instead of using plaster?

   A: All three panelists use plaster. Plaster casting works well for Dr. Milch, who usually uses suspension casting with the patient supine. If patients will not relax and instead fire their quadriceps and anterior tibialis muscles, he will use a prone casting technique. When fabricating accommodative devices, Dr. Milch marks lesions with a felt-tip marker and uses a semi-weightbearing technique.

   As an alternative to plaster casting, Dr. Milch acknowledges the STS sock cast and scanning. In the end, he says what matters most is how one captures the foot position when the plaster sets.

   Dr. Williams has used the CustomSelect Scanner (Amfit) for the past year. He says the product permits him to program everything he wants in a prescription and he can see it in 3D before the orthotic is produced. The scanner also lets Dr. Williams add heel lifts, medial or lateral heel skives, a first ray groove/trough or holes for plantarflexed metatarsals or plantar fibromas. The scanner lets him invert the device in varus or valgus, or only to the metatarsophalangeal joint.

   Although he acknowledges that plaster casting can be messy, Dr. Horowitz believes it is less expensive than other casting methods and more accurate. He casts patients himself, noting that he tries to lock the midtarsal joint in the traditional manner of dorsiflexing the lateral rays. Lately, he has been paying more attention to capturing the lateral column accurately. Dr. Horowitz usually casts most if not all of a flexible forefoot varus.

   Plaster works well if the technique is sound and can be repeated, according to Dr. Williams. He usually uses the same casting method, casting in a position that is slightly pronated from the subtarsal joint (STJ) neutral position. Dr. Williams says doing so facilitates a more comfortable patient fit and still has the same function. Dr. Williams will occasionally cast a patient in STJ neutral but only does so for those with severe flat feet and medially deviated STJ axes. Such an STJ neutral technique works well for some patients with AFOs and Richie braces but Dr. Williams advises DPMs not to overdo it since it may cause more problems than it solves.

Dr. Horowitz is a member of the American Academy of Podiatric Sports Medicine. He is board certified by the American Board of Medical Specialties in Podiatry. He practices in Bowie, Md.

Dr. Milch is a member of the American Academy of Podiatric Sports Medicine. He is certified in podiatric orthopedics by the American Board of Podiatric Orthopedics and Primary Podiatric Medicine. He practices in Asheville, N.C.

Dr. Williams is a Fellow of the American College of Foot and Ankle Surgeons, and is board certified by the American Board of Podiatric Surgery. He is a member of the American Academy of Podiatric Sports Medicine. Dr. Williams practices in Merrilville, Ind.

Dr. Levine is in private practice and is also the director and owner of Physician’s Footwear, an accredited pedorthic facility, in Frederick, Md.

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