Post-Op Orthotics: Can They Have An Impact?

David J. Levine, DPM, CPed

   The device included a neutral heel cup with 0° of motion in order to try and balance the heel at contact. Cushioning was also important at heel strike because of the lack of the subtalar joint motion. Total contact of the foot was important during midstance in order to try and distribute the weight more evenly across the foot. First ray accommodations were necessary for the propulsive phase of gait. The purpose of this was to try to allow the first ray to plantarflex and promote propulsion from the first ray.

Other Pertinent Considerations

The asymmetry in the function between her feet was also indicative of another factor, namely a leg length discrepancy. With the feet now being structurally and functionally different after the surgery, one must at least check for a leg length discrepancy. The operated foot had been collapsed prior to the surgery, perhaps making it function as though it was the shorter side. Now that there has been reconstruction of this foot, it could go from being on the short side to being on the long side. Complaints of back and hip pain are the clues that one may need to assess more closely for leg length discrepancy. Gait analysis is also an excellent way to elucidate issues like this.

   Regardless of how successful new orthotic devices are, you cannot ignore the shoes. First of all, one need to ensure proper measurement of the size of her feet is necessary. It is possible that foot size or width can change after certain procedures. Also bear in mind that the foot can feel different to the patient, causing a change in how it feels inside of a shoe and leading to a different size. This is often a subjective issue but patients become much more aware of their feet following surgery as they may notice details and sensations they did not preoperatively. The shoe should have the toe break in the proper location. The ball of the foot should fit into the widest part of the forefoot of the shoe. The shank of the shoe should be stable in the frontal as well as the sagittal planes.

   Proceeding through these steps of care and allowing for time to see how the patient adapts and responds is important. This enables you to carefully assess the impact of the changes. Changing too many things at one time not only can make it difficult to determine the success of the treatment but it may also introduce other problems or complaints. Documenting each step of the care, even when the changes are small, will help you later on if initial attempts have been unsuccessful. You can then see a map of where you started and gain some ideas as to what might be worth trying next.

   Despite the efforts with the shoes and orthotic devices, sometimes it is still not enough as was the case with this patient. Since she was still having difficulty with propulsion, the clinician added forefoot rocker soles to the shoes the patient wore most of the time. These modifications assisted the patient’s forward progression once her center of weight moved into the forefoot of the shoe. This is unlike some of the new shoes on the market now that exhibit rocker soles. Many of these shoes have rocker soles that are in the rearfoot. The rearfoot type of rocker makes the foot unstable and may actually hinder propulsion. Also, with some individuals, one needs to take the angle and base of gait in to account when adding rocker soles, which is obviously impossible with some of the shoes that are available now.

Final Notes

Orthotic devices have been an integral part of conservative treatment for foot and related complaints for over a century. Initially, the purpose of orthotic devices was to provide more support for the foot. As the field of biomechanics evolved, it was more than support that orthotic devices could offer. Controlling the motion of the foot became an important consideration as well as alleviating areas of pressure. In certain situations, a combination of support, controlling motion and distributing pressure is necessary. One can accomplish this with a variety of designs made from a wide array of materials. Sometimes, it is necessary to combine the purposes of an orthotic device.

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