Pertinent Pearls On Custom Orthoses And Modifications

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Author(s): 
Clinical Editor: Nicholas Romansky, DPM

Q:

Do you have any pearls on the effective use of custom orthotics on the kinetic chain other than feet?

A:

Since the foot is the location of the compensation for what happens more proximally within the kinetic chain, Dr. Levine stresses the importance of assessing the legs, knees, thigh segment, hips and low back both from a static as well as a dynamic perspective.

   Dr. Kirby agrees about the importance of addressing biomechanics.

   “The podiatrist who understands how foot function affects the biomechanics of the lower extremity and how lower extremity function affects the biomechanics of the foot, and can implement this knowledge into effective custom foot orthosis prescriptions for their patients will always be a very valuable member of the medical community. He or she will be able to offer conservative treatment options to patients who are reluctant to take the time away from work, experience the postoperative disability and encounter the risks of surgical treatment options,” asserts Dr. Kirby.

   Dr. Jordan emphasizes the importance of ascertaining a full history and physical to determine if the pathomechanics of the feet are contributing to the proximal concerns or complaints. He says one must determine if the child’s feet are the driving force affecting the proximal pathomechanics or if the pedal structures are expressing a proximal musculoskeletal disorder.

   “Conditions labeled as growing pains, patellofemoral pain syndrome, trochanteric bursitis (from extremes of internal femoral rotation), peroneal muscle spasm (such as tarsal coalitions with equinus) or Osgood-Schlatter disease are but a sampling of the many complaints that are effectively and quickly addressed through custom fabricated orthoses,” says Dr. Jordan.

   Dr. Jordan says the key, after knowing the pain is not due to systemic medical conditions, is distinguishing between the pathomechanical “findings” and the “problem(s).” After identifying the problem, he notes he and his colleagues have been 99 percent successful in resolving pain associated with recalcitrant “growing pains” and similar overuse syndromes that manifest as pain above the foot.

   Dr. Kirby notes the potential of using custom orthoses to reduce the pathological internal loading forces that cause a number of injuries. Such injuries include: leg injuries such as medial tibial stress syndrome, peroneal muscle fatigue, posterior tibial and peroneal tendinitis/tendinosis; knee injuries such as patellofemoral pain syndrome, iliotibial band syndrome, medial and/or lateral compartment osteoarthritis and pes anserinus bursitis; and many mechanically-related hip and low back complaints.

   “I often tell patients that the further you go away from the feet, the harder it is to predict how successful the orthotic devices will be in alleviating their complaints,” says Dr. Levine. “We have all had patients for whom orthotic devices have aided in resolving back pain so we know that there is an effect throughout the kinetic chain.”

Q:

How do you determine which topcover to use?

A:

In a pediatric practice, Dr. Jordan notes that topcovers are not necessary and all too often take up needed space within the child’s footwear. He argues that cellular cushioning topcovers for added shock absorption, comfort and protection are unwarranted, even for the child with an insensate spina bifida foot or the high arched foot type of Charcot foot.

   More important are the shock absorbing materials of the footwear that come into contact with the ground well before the foot structures do, according to Dr. Jordan. He notes that often the child’s plantar soft tissues, which are contained within the orthosis shell, offer considerably greater impact shock absorption than a topcover.

   Dr. Levine says one can use a variety of topcovers ranging from thin leather to thick Spenco, emphasizing that the key factor is how the orthotic will fit the shoe. In many instances, he says it is easier to remove the insole of the shoe and replace it with a full-length device that will occupy approximately the same volume.

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