Emerging Insights On Orthotic Prescriptions And Modifications

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Guest Clinical Editor: Paul Scherer, DPM

   Drs. Kashanian and Choate cite the usage of sweet spots. In Dr. Choate’s experience, successful sweet spots are usually deeper and wider than one would initially order on the prescription. Due to the movement of the foot throughout each step, she advises a more “generous” sweet spot to provide more room for errors in placement. Dr. Choate also recommends filling the sweet spot only partially with soft padding and letting the top cover enhance the cushioning for the area in question.

   Dr. Kashanian notes one often prescribes sweet spots to offload symptomatic bony and soft tissue prominence in the plantar aspect of the foot. She says one can treat a symptomatic tight plantar fascia or a painful plantar fibroma with a plantar fascial groove at the appropriate area. In addition, Dr. Kashanian suggests treating a painful rheumatoid cartilaginous nodule with a sweet spot in the orthotic shell. Dr. Kashanian says a sweet spot can also offload a protruding and painful styloid process.

   Dr. Sundstrom does not order such accommodations initially unless there is a severely tight/prominent plantar fascia in a rigid cavus foot or a prominent navicular tuberosity in a rigid flatfoot. Dr. Sundstrom will order accommodations as an adjustment later if the orthotic is not accommodating the deformities/prominences. She utilizes slot apertures on forefoot extensions quite often.

    “I cannot stress enough the importance of balancing the weight distribution under the met heads/forefoot properly,” says Dr. Sundstrom.

   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 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.

   Dr. Scherer is a Clinical Professor at the Western University of Health Sciences College of Podiatric Medicine at Pomona, Calif. He is also the CEO of ProLab Orthotics/USA.


1. Mickle KJ, Steele JR, Munro BJ. Does excess mass affect plantar pressures in young children? Int J Pediatr Obes 2006; 1(3):183-88.
2. Lin CJ, Lai KA, Kuan TS, Chou YL. Correlating factors and clinical significance of flexible flatfoot in preschool children. J Ped Ortho 2001; 21(3):378-82.
3. Roukis TS, Scherer PR, Anderson CF. Position of the first ray and motion of the first metatarsophalangeal joint. JAPMA 1996; 86(11):538-46.
4. Scherer PR, Sanders J, Eldredge DE, et al. Effect of functional foot orthoses on first metatarsophalangeal joint dorsiflexion in stance and gait. JAPMA 2006; 96(6):474-81.
5. Munuera P, Dominguez G, Polomo I, Lafuente G. Effects of rearfoot-controlling orthotic treatment on dorsiflexion of the hallux in feet with abnormal subtalar pronation. JAPMA 2006; 96(4):283-9.
7. Vohra PK, Kincaid BR, Japour CJ, Sobel E. Ultrasonic evaluation of plantar fascia bands: a retrospective study of 211 symptomatic feet. JAPMA 2002; 92(8):444-9.
6. Kogler, GF, Veer FB, Solomonidis SE, Paul JP. The influence of medial and lateral placement of orthotic wedges on loading of the plantar aponeurosis. J Bone Joint Surg Am 1999; 81(10):1403-13.

   Editor’s note: For further reading, see “Key Insights On Writing Orthotic Prescriptions” in the January 2006 issue of Podiatry Today.

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