Current Concepts In Orthotic Prescriptions
With the recent increase in the popularity of soccer, what type of orthotic device do you prescribe for soccer injuries or prevention, considering the extremely low volume of soccer shoes?
Dr. Sanders tailors the orthotic to the specific pathology. For example, she uses a medial heel skive for a medially deviated subtalar joint axis and minimum fill and/or inversion for excessively pronated rearfoot.2-5 She advocates using a shallow heel cup of 8 to 10 mm.
Likewise, Dr. Sundstrom prescribes orthoses based on the patient’s pathology. For those with frequent inversion ankle sprains, she will incorporate a valgus forefoot extension. If the problem is jamming in the first metatarsophalangeal joint or functional hallux limitus, she adds a reverse Morton’s extension. For Dr. Sundstrom, flatfoot “is probably the most challenging problem when dealing with a low profile soccer cleat” because the necessary components use so much room in the shoe.
Carbon graphite is Dr. Sanders’ preferred orthotic material for soccer cleats due to the low volume. Similarly, Dr. Kashanian most frequently recommends that soccer players use a graphite functional device. Given the low profile of the carbon graphite material, Dr. Kashanian says the orthosis does not need a lot of room in the soccer shoe. She says one can add a skive to the functional graphite orthoses or inverted skives for biomechanical control. Dr. Kashanian says the one disadvantage of graphite orthoses is the inability to incorporate a sweet spot or plantar fascial groove in the shell. Due to the low volume of the soccer cleat, she does not recommend a bulky rearfoot post.
Regardless of pathology, Dr. Sundstrom uses a low-profile device. She prefers a semi-rigid polypropylene shell with no rearfoot post, a shallow heel cup and a narrow or medium width. The device should also have minimal cast fill and a medial skive, usually with some degree of inversion, according to Dr. Sundstrom.
Dr. Sundstrom uses a thin EVA or Spenco-type topcover on the sulcus while Dr. Sanders uses a vinyl topcover. She says this holds up best against sweat and friction. Furthermore, Dr. Sundstrom recommends that patients wear a more supportive type of device, which provides better control, in their street shoes the remainder of the time.
Noting that she does not prescribe a high volume of soccer orthotics, Dr. Choate’s first goal is making sure the device fits in the shoe.
“I can order a great orthotic but if it is too bulky to fit in the shoe or causes neuralgia during use, then it is not the best choice for the situation,” notes Dr. Choate.
To that end, Dr. Choate uses a low-volume, streamlined device such as a graphite shell with a thin, somewhat stiff topcover to the toes. In addition, to add stability and protection for the ankle and foot on uneven terrain, she recommends using a 1/16-inch reverse Morton’s extension and minimal lateral bevel on the rearfoot post.
Citing the number of inversion injuries in soccer, Dr. Choate suggests the use of an ankle brace if the patient has any history of ankle sprains. She cautions that the brace and orthotic may be competing for space. In many active patients, she uses the Active Ankle Brace (Active Ankle). Dr. Choate notes the device’s plate fits under the rearfoot area of the orthotic and provides “excellent control” of frontal plane motion.
Dr. Choate is an Assistant Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University.
Dr. Kashanian is in private practice in Los Angeles. She is a Medical Consultant for ProLab Orthotics/USA in Napa, Calif.
Dr. Sanders is in private practice in San Francisco. She writes a monthly blog for Podiatry Today. For more information, please visit www.podiatrytoday.com/blogs. Dr. Sanders also blogs at www.drshoe.wordpress.com .
Dr. Sundstrom is affiliated with the Orthopedics, Podiatry and Sports Medicine Department in the Division of Musculoskeletal Services at the San Francisco Kaiser Permanente Medical Center. She is board certified in foot surgery and in reconstructive rearfoot and ankle surgery.