Inside Insights On Evidence-Based Orthotic Therapy

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Inside Insights On Evidence-Based Orthotic Therapy
Here one can see adult-acquired flatfoot secondary to posterior tibial tendon dysfunction. Lawrence Huppin, DPM, says there are evidence-based prescription recommendations for adult-acquired flatfoot and various other conditions.
Guest Clinical Editor: Lawrence Huppin, DPM

      As Dr. Choate notes, these publications each led to a similar conclusion: a pronated position leads to increased pressure in the tarsal tunnel and increased tension on the structures within the tarsal tunnel. She speculates if there may be a treatment option to fill the gap in the care of tarsal tunnel. Dr. Choate is increasing her use of functional orthotics that control subtalar joint pronation. She hopes with time, she will discover which orthotic modifications used for pronation control (such as medial skives, deep heel cups, Blake inversions or firm posting) are the best combination for improving tarsal tunnel symptoms.

      For subcalcaneal pain secondary to plantar fascia overload, Dr. Richie cites literature showing that a custom device addressing supination compensation around the midtarsal joint’s longitudinal axis will most effectively relieve pain and permit a successful treatment outcome.

      “I am convinced now, more than ever, that a custom functional foot orthosis, fabricated from a proper neutral suspension cast, has the best opportunity to offload strain of the medial-central band of the plantar aponeurosis,” claims Dr. Richie.

      Dr. Richie cites several studies for offloading the plantar fascia. He says all the studies validate the theory that an orthosis that provides an eversion moment to the longitudinal axis of the midtarsal joint will elevate the arch and reduce plantar fascia strain.

      Many DPMs feel comfortable treating metatarsalgia with functional orthoses and Dr. Huppin says there have been a significant number of articles that help define exactly how DPMs should be writing orthotic prescriptions for the common condition. As he notes, Chalmers demonstrated in 2000 that for rheumatoid arthritis patients with metatarsalgia, semi-rigid orthoses are much more effective than soft orthoses.8 In a 2006 study, Mueller and Hastings demonstrated that a total contact insert with a metatarsal pad was the most effective technique of unloading a metatarsal head.9 A 2003 study said that one should place the highest point of a metatarsal pad between 6 mm and 10 mm behind the point of maximum pressure on the metatarsal head.10

      Based on the literature, for metatarsalgia, Dr. Huppin recommends a semi-rigid polypropylene orthosis with a minimum cast fill, wide orthotic plate, a cushioned topcover left unglued on the front half of the orthosis and a metatarsal pad. The podiatrist should adjust the metatarsal pad in the office so the highest point is about 8 mm behind the painful metatarsal head, suggests Dr. Huppin.

      Dr. Choate is an Adjunct Assistant Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt College. She practices at For Feet’s Sake in Berkeley, Calif.

      Dr. Huppin is an Adjunct Associate Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine. He is also the Medical Director for ProLab Orthotics/USA.

      Dr. Richie is an Adjunct Associate Clinical Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine. He is in private practice in Seal Beach, California. He can be reached at


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