Adding A Crest Pad To Custom Orthoses

Larry Huppin DPM

A patient recently came in to pick up her orthotic devices. She has worn orthoses for years for several pathologies. However, what we are addressing now is pain secondary to digital contracture. She is starting to get more pain at the distal aspect of her toes secondary to hammertoes and pressure on the distal aspect of the digits. In the past, she has found that shoes that have a crest in them tend to work well for her. In particular, she has found that the crest in Birkenstock sandals helps keep her toes straight and decreases her symptoms. Given that the crest has been effective for her with the sandals, we wanted to add a crest pad to her orthotic devices.

If you are going to try and add a crest pad to orthoses, it is critical to place the crest pad in the right position. For this reason, I do not think it is something that the orthotic laboratory should add to the orthoses. It is just too subjective as to where the patients like these crest pads to be placed to have the orthotic lab add them.

The patient arrived today to pick up her new orthoses, which are polypropylene with a full-length cover along with a layer of Poron glued to the bottom of the EVA cover. The orthoses appeared to fit very well. In order to place the crest pad in the correct position, I took the patient to the orthoposer and had her stand on it. I then placed lipstick on the distal aspect of each toe and each metatarsal head. I then had her stand directly down on the orthoses so the lipstick would transfer and indicate where the toes and metatarsal heads were. Obviously, the sulcus would lie between these two areas. After that, I placed a piece of white paper down over the top of the orthoses so the mark would transfer to the paper. I then cut a template out of the paper and used it to trim a piece of 3 mm sticky felt to the shape of the crest that I wanted. I then placed this on the bottom of the orthotic top cover.

I am going to let her wear this for a couple of weeks and then have her return to clinic. It is fairly subjective how high the crest pad should be to make her the most comfortable so we will add or subtract from this temporary crest pad until she is as comfortable as we can possibly get her. At that point, I will remove the felt and make one out of Korex. I will glue that to the bottom of the cover and then place a Vinyl bottom cover on the orthoses.

This is an uncommon modification but it is a useful one for some patients. Again, my biggest piece of advice for making this type of modification is to do it in the office and not order it from the orthotic lab.

Editor's note: This blog was originally published at . It has been adapted with permission from Lawrence Huppin, DPM, and ProLab Orthotics. For more information, visit .

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