Do Podiatrists Use First Ray Cutouts Too Much?

Larry Huppin DPM

The first metatarsal cutout or first ray cutout is a common orthotic modification clinicians use to allow the first ray to plantarflex in order to treat functional hallux limitus. I think it should be noted, however, that if a practitioner takes extremely good negative cast, writes an appropriate prescription, uses an orthotic lab and does not overfill the medial arch, the first ray cutout should rarely be necessary.

The orthosis goal in the presence of functional hallux limitus is to allow the first ray to plantarflex. One can accomplish this by plantarflexing the first ray while taking the negative casts, prescribing a minimum cast fill with approximately 2 to 3 degrees of inversion and ensuring that your orthotic lab does not overfill the medial arch.

When podiatrists have achieved these objectives, the first ray should plantarflex quite effectively in order to decompress first MPJ motion and enhance a windlass function. Making an orthosis in this manner will help ensure that it conforms very closely to the arch of the foot when the foot is held in neutral position with the first ray plantarflexed. It should conform closest posteriorly and flare away from the foot anteriorly.

As all of the doctors in my clinic follow these guidelines when treating functional hallux limitus, we never prescribe first ray cutouts.

I do, however, use first ray cutouts in my office on occasion. The most common time I do so is when the patient comes in with an orthosis received from another practitioner and the orthotic device does not conform very close to the arch of the foot. In this situation, with the foot having to flatten and the first ray having to elevate in order to reach the orthosis, I want to somehow enhance plantarflexion of the first ray. The first ray cutout or first metatarsal cutout, along with a reverse Morton’s extension, is a good option in this situation.

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



Do you have any evidence to back up your claims as to the lack of value of properly utilized first ray cutouts as an orthotic shell ORF?

As you rarely make them, offer them and do not personally use them, opining their extinction seems biased.

I would sooner state that the evidence is leading towards the extinction of subtalar joint neutral casting as you and ProLab suggest.

Picciano A, Rowlands M, Worrell T: Reliability of open and closed kinetic chain subtalar joint neutral positions and navicular drop test; J Orthop Sports Phys Ther, Oct 1993; 18(4):553-8

Lee W, Lee C, MPhil A, Hutchins S: Is it important to position foot in subtalar joint neutral position during non–weight-bearing molding for foot orthoses?; Jour Rehab Research Dev 2012; vol 49 (3), pp459-466

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