Orthotic Modifications And Shoewear For Specific Jobs

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Author(s): 
Clinical Editor: Nicholas Sol, DPM, CPed

Q: How do you handle orthotic prescriptions for patients who carry, push and pull loads on uneven surfaces (i.e. construction, landscaping)?
A:
In Dr. Scherer’s experience, mail carriers with stable and unstable midtarsal joint (MTJ) usually suffer from overuse syndromes of plantar fasciitis and lateral leg pains and fatigue.
An orthotic device for the mail carrier will bridge the forefoot to rearfoot, limiting motion of the MTJ and reducing muscle activity devoted to that effort, according to Dr. Scherer. However, the casting of the device is important. An orthotic that holds the MTJ in an even slightly supinated position will encourage motion and defeat its purpose. Casting the foot with the medial column plantarflexed ensures a good position of the MTJ, maintains Dr. Scherer.
Many podiatrists also add a reverse Morton’s extension to the devices, which requires a topcover. Dr. Scherer thinks the rationale is to encourage the first ray to plantarflex during stance and protect overuse of the peroneus longus. He says a vinyl topped EVA combination provides the durability needed for a mail carrier who walks frequently. For shoes, he recommends a thick sole, rigid shank and removable insole.
Drs. Stern and Mathur say when patients carry something in their arms, they are increasing weightbearing for the entire gait cycle. There is a little deviation of the center of gravity anteriorly, depending on the weight of the carried item. In order to provide for medial to lateral stability, they say “these individuals may need a softer orthotic with greater shock absorption to adapt to uneven surfaces.”
For those patients who carry loads, Drs. Stern and Mathur may provide orthotic accommodation via a deep heel cup and Shafer plate. Padding the entire device can help with increased weights.
When pushing loads, patients probably don’t need a lot of control in the heel area because of decreased weightbearing, although they still need midfoot control with a padded Shafer plate, the doctors maintain. They say you can achieve forefoot control for these patients via a small soft metatarsal pad and possibly metatarsal head accommodation. Drs. Stern and Mathur note that a cutout under the first metatarsal head and padded forefoot extensions might be beneficial, and they also add normal rearfoot posting for pushing and pulling.
Pulling loads requires increased control of the rearfoot, so Drs. Stern and Mathur add a deep heel cup and may increase rearfoot posting by 1 to 2 degrees. When treating these patients, they try to control any abnormal plantar pressure by accommodating the area of increased pressure.
If patients need to be on their toes because of the weight of the object they are pushing, Drs. Stern and Mathur say they’ll accommodate the forefoot forces by using a metatarsal pad and a cutout around the first metatarsal head.

Dr. Stern is a Fellow of the American College of Foot and Ankle Surgeons. Dr. Mathur is a first-year resident at Providence Hospital in Detroit.
Dr. Scherer is Chair of the Applied Biomechanics Department of the California School of Podiatric Medicine at Samuel Merritt College and Medical Director of ProLab Orthotics/USA.
Dr. Weil is CEO and President of the Weil Foot and Ankle Institute and is a Fellow of the American College of Foot and Ankle Surgeons. Dr. Weil is also a consultant for Langer, Inc.

Dr. Sol (pictured at right) founded the Walking Clinic, PC and practices in Colorado Springs, Colo.

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