Key Insights On Orthotic Fabrication And Replacement

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Guest Clinical Editor: David Levine, DPM, CPed

   Dr. Firestone will generally stick with carbon fiber orthotics when he is looking for a lightweight, durable orthotic, which is important in runners who are looking to keep their running shoes as light as possible. He will also use carbon fiber for dress orthotics since that material is generally lower profile. Dr. Firestone uses polypropylene orthotics for severe overpronators, patients who need better accommodation in the shell and those he feels may need a future adjustment to the shell. He prefers full-length orthotics for athletic shoes and three-quarter length orthotics for dress shoes. Dr. Firestone will fabricate a tri-laminate orthotic with a combination of polyethylene, PPT, ethylene vinyl acetate (EVA) and Plastazote when he is looking for better accommodation.

   Dr. D’Amico suggests examining the treatment objectives, which can include restriction of motion and enhancement of motion, in order to better select the type and prescription needs for the individual orthotic. The more information one gathers and the more thorough the examination, it is more likely that one will select the ideal foot orthosis and achieve the optimum foot function.

   Dr. Levine adds that often there is a challenge with lab consistency in regard to the fabrication of orthotic devices. The amount of fill a lab uses on the positive cast will determine how closely the device fits up against the foot, according to Dr. Levine. As he notes, there are some devices that fit like a glove and others that have very little contour.


How do you address shoe selection when recommending orthotic devices?


As the shoe is an extension of and container for the orthotic device, Dr. D’Amico emphasizes it can either assist or detract from the orthotic’s function. Since shoes that have become misshapen as a result of compensatory pathomechanics prior to orthotic dispensing will negatively impact orthotic effectiveness and function, he advises starting with a relatively new shoe when dispensing orthotic devices. Dr. D’Amico says this allows one to house the device on a flat surface with medial and lateral “walls” to keep it in place and securely positioned. Along these lines and for most patients, he would recommend straight last shoes with a rigid counter, a longitudinal stability and a shoe capable of sagittal plane flexibility at the MPJs (or forefoot). The type of device would indicate whether there would be the need for a removable insole.

   The key to an effective outcome, says Dr. Levine, is to prepare the patient for what to expect when receiving the orthotic devices so he or she will understand how they will fit and function the best.

   “Dispensing a pair of orthotic devices for athletic shoes when the patient only wears dress shoes will be a failure. The orthotic device will only be as good as the shoe in which it is placed,” explains Dr. Levine.

   Dr. Firestone recommends that patients bring their orthotics to the shoe store when purchasing new shoes. He also suggests buying shoes with removable insoles when possible to better accommodate the orthotics. Furthermore, Dr. Firestone says patients should purchase dress shoes with heel heights of no more than 1.5 inches and purchase new shoes later in the day after feet have had a chance to swell a little.

   Dr. D’Amico is a Professor and Past Chairman in the Division of Orthopedics at the New York College of Podiatric Medicine. He is a Diplomate of the American Board of Podiatric Medicine, and a Fellow of the American Academy of Foot and Ankle Pediatrics. Dr. D’Amico is in private practice in New York City.

   Dr. Firestone is board certified in Foot Surgery by the American Board of Podiatric Surgery. He is a Fellow of the American College of Foot and Ankle Surgeons, and the American Academy of Podiatric Sports Medicine. Dr. Firestone is in private practice in Washington, DC.

   Dr. Levine is in private practice and is also the director and owner of Physician’s Footwear, an accredited pedorthic facility, in Frederick, Md.

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