Ensuring Orthotic Efficacy For Adults And Children

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Author(s): 
Guest Clinical Editor: Joseph D'Amico, DPM

   Dr. Jordan has had excellent outcomes by assessing the total varus of the lower limb and foot, and providing the total posting needed to align the lower limb above the weightbearing foot. He notes medium density post material, which may be incorporated as a filler beneath a thin thermoplastic shell, is more resistant to pathological compensation than acrylic while being forgiving where mobility is desirable.

Q:

Some practitioners develop consistently high successful outcomes with a particular type of orthosis. Is there a “signature” device you frequently prescribe that yields these type of results?

A:

Most often, Dr. Valmassy will prescribe a device fabricated of polypropylene 3/16 inches thick. In stylish shoes, he will utilize a more flexible device such as a 1/8-inch polypropylene orthosis although he notes a more rigid device is appropriate in most instances. Often Dr. Valmassy will invert the rearfoot anywhere from 5 to 8 degrees and utilize a medial calcaneal skive from 2 to 6 degrees. The heel cup will typically be 16 mm, which he often increases to 18 or 20 mm depending on the severity of the problem. Dr. Valmassy frequently considers a 10 to 12 mm heel cup in cases of minimal correction or for a forefoot valgus deformity.

   Dr. Valmassy’s signature devices have a flat rearfoot post with no motion. However, if he is trying to reduce shear forces at heel contact and strike, he will utilize a 4-degree post with 4 degrees of motion for a retrocalcaneal exostosis or a retrocalcaneal bursitis.

   Noting the multifaceted aspects of growing and developmentally changing children, Dr. Jordan does not have a signature orthosis design, style or material.

   “Using such an orthosis would suggest that all kids are essentially the same and their biomechanical issues are very similar in their daily routine of play. They are not,” he says.

   Similarly, Dr. Volpe does not have a signature orthosis, noting “the beauty of custom foot orthoses is that they can be tailored exactly to the clinical circumstances of a particular patient.” However, he does like the Dynamic Stabilizing Innersole System (DSIS) and University of California Biomechanics Lab (UCBL) type devices — which have high flanges and deep heel seats — in toddlers and young children with lax body types and high-motion flat feet. Dr. Volpe also uses gait plate extensions frequently to manage the in-toe component that frequently accompanies a pediatric flatfoot.

   Dr. Jordan notes that most often, the orthoses in a pediatric practice should address the lateral column along the lateral-plantar aspect of the shell. As he says, one cannot expect a deep heel cup to “control” the calcaneus. Dr. Jordan notes the interface between the plantar fat pad and calcaneus has joint-like qualities where motion will occur regardless of how deeply and tightly the fat pad is squeezed.

   “An orthosis design must be individualized with specificity to the primary problem, age group, developmental status and pathomechanics involved,” maintains Dr. Jordan. “An orthosis must be designed to fit the child’s needs rather than demand that the child fit an orthosis that the practitioner feels most comfortable prescribing.”

Q:

What is your protocol for assessing orthotic effectiveness?

A:

When assessing the orthosis, Dr. Volpe asks patients how they feel in the device and how any particular complaints respond to the device. Likewise, at the follow-up visit, Dr. Valmassy questions patients on what effect the orthotic devices had on their symptoms.

   Dr. Volpe also looks at patients weightbearing without their orthoses and then with their orthoses, and takes measurements to determine the degree of control in the devices. Dr. Volpe retakes those measurements later on to see if some of the control has been “lost.”

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