Pertinent Pearls On Orthotic Adjustments And Casting
Dr. Horowitz has used an increased number of first metatarsal head and first ray cutouts to increase the proper function of the first ray. He usually calls on the lab to grind the extrinsic rearfoot post as thin as possible with little to no medial grind-off. Dr. Horowitz uses a heel cup as deep as the shoe permits. Generally, he uses minimal fill when fabricating a longitudinal arch so the device will fit the arch closely.
When Dr. Milch adjusts orthotic prescriptions, he commonly does so to increase the amount of desired control. For a patient with an extremely pronated foot, for whom an ankle foot orthotic (AFO) is inappropriate, he will use a medial heel skive, deeper heel cup height, wider grind, firmer material and rearfoot posting with a medial flange. He adjusts prescriptions according to the patient’s activity. For example, Dr. Milch will use a softer flexible material for a runner. For a patient with a leg length discrepancy of 1/4 inch or less, Dr. Milch will add that amount of discrepancy to the rearfoot post. For a discrepancy of more than 1/4 inch, he incorporates the additional lift into the midsole.
Q: Once orthotic devices are fabricated, what adjustments or modifications do you perform yourself and what type of adjustments do you return to the orthotic lab?
A: Drs. Horowitz and Milch both make use of grinders and heat guns. Dr. Horowitz notes the practicality of those tools, saying he can use a heat gun to lower an arch, grind off the medial distal rearfoot post or diminish rearfoot posting.
Dr. Horowitz also keeps topcover materials, metatarsal pads and rearfoot wedges in his in-office lab. He says they allow him to adjust orthotics more easily and enable him to have more control over the fabrication parameters that he orders from the lab. At times, Dr. Horowitz will have the orthotic lab leave a front extension unglued so he can place a metatarsal pad where he wants it when a patient presents for the dispensing of an orthotic. Dr. Horowitz formerly replaced top covers himself, especially when treating athletes, but he now sends them back to the lab since he found the process too time-consuming.
Like Dr. Horowitz, Dr. Milch uses a heat gun to lower arches. He will add Korex to the medial aspect of the rearfoot post and along the medial arch, which inverts the device, to gain more control. However, if an orthotic is too narrow, Dr. Milch will send it to the lab. If he makes three or more attempts at an adjustment and patients are still having trouble with the orthotic, Dr. Milch will send it back to the lab, noting that he and the orthotist can usually solve the problem. Dr. Milch notes that sometimes he will need to recast the patient and start over.
Dr. Williams does “99 percent” of orthotic adjustments himself, saying is it difficult for him to explain what he wants to someone over the phone. He keeps a sani-grinder in each of his two offices. He and his staff perform all topcover refurbishments and he will make all modifications of rearfoot posts for heel lifts, forefoot and rearfoot posting, and for first ray cutouts. If Dr. Williams has a serious problem with an AFO, he will return it to the lab but notes this is an isolated incident. Even if there is a problem with an AFO, Dr. Williams says one can use PPT and a heat gun to fix most problems.
“Personally, I think it makes you look bad if you cannot fix something in the office the same day or at least within a day or two,” says Dr. Williams. “Top cover replacements may take a week but they are a different story.”
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?