Inside Insights On Evidence-Based Orthotic Therapy

Guest Clinical Editor: Lawrence Huppin, DPM
      “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



1. Kogler G, Veer FB, Solomonidis, SE. The influence of medial and lateral placement of orthotic wedges on loading of the plantar aponeurosis. J Bone Joint Surg; 1999;81A:1403-1413.
2. Kogler GF, Solomonidis SE, Paul JP: Biomechanics of longitudinal arch support mechanisms in foot orthoses and their effect on plantar aponeurosis strain. Clin Biomech 11:243-251, 1996.
3. McClay-Davis I, Laughton C, Williams, DS. A comparison of four methods of obtaining a negative impression of the foot. J Am Podiatr Med Assoc. 2002 May;92(5):261-8.
4. McPoil TG, Schmit D. Forefoot to Rearfoot Angle–A Comparison of Orthotic Casting Techniques. Phys Ther. 1989 Jun;69(6):448-52.
5. Kinoshita M, et al. The Dorsiflexion-Eversion Test for Diagnosis of Tarsal Tunnel Syndrome. JBJS 83:1835-39, 2001.
6. Labib J, et al. Heel Pain Triad: The Combination of Plantar Fasciitis, Posterior Tibial Tendon Dysfunction and Tarsal Tunnel Syndrome. Foot and Ankle Intl 23(3):212-219, 2002.
7. Trepman M, et al. Effect of Foot and Ankle Position on Tarsal Tunnel Compartment Pressure. Foot and Ankle Intl 20(11):221-26, 1999.
8. Chalmers AC, Busby C. Metatarsalgia and rheumatoid arthritis--a randomized, single blind, sequential trial comparing 2 types of foot orthoses and supportive shoes. J Rheumatol. 2000 Jul;27(7):1643-7.
9. Mueller MJ, Lott DJ, Hastings M. Efficacy and mechanism of orthotic devices to unload metatarsal heads in people with diabetes and a history of plantar ulcers. Phys Ther. 2006 Jun;86(6):833-42.
10. Hastings MK, Commean PK. Aligning anatomical structure from spiral X-ray computed tomography with plantar pressure data. Clin Biomech 2003 Nov;18(9):877-82.
Additional References
11. Scherer PR: Heel spur syndrome. Pathomechanics and nonsurgical treatment. J Am Pod Med Assoc 81:68-72, 1991.
12. Sarafian SK: Functional characteristics of the foot and plantar aponeurosis under tibiotalar loading. Foot Ankle 8:4-17, 1987.


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