Too often, physicians prescribe custom fabricated orthoses to treat a forefoot issue when they can address the problem through the use of a semi-custom orthotic.
Do we need to cast, mold and scan the foot, et cetera, to produce a custom rearfoot shell, which we can attach to the forefoot device? Do we need to control the rearfoot to help the forefoot pathology? The debatable answer is that it depends on the pathology.
Regarding neuromas, when ordering an orthotic, one can simply check the box to insert a neuroma pad on the forefoot between the involved metatarsals. The goals of the pad are to splay the metatarsals and reduce the irritation to the nerve. One can greatly minimize the expense of the custom orthotic by implementing a semi-custom insert.
Podiatrists can create these semi-custom inserts or they can utilize a pedorthist. In my practice, I send patients to a specialty shoe store, Lucky Shoes (www.luckyshoes.com  ), which uses a prefabricated shell and modifies the forefoot with the appropriate material to offload or make adjustments.
The use of pedobarography determines the placement of the insert. This can be as simple as using carbon paper to identify the pressure areas for locating the metatarsals. Any modifications are simple and podiatrists can add, remove or adjust the orthotic for perfect placement. There is no need to construct an expensive shell as this is a temporary device to help address a forefoot problem.
When trying to construct semi-custom devices with outside laboratories, practitioners need to send the device back for minor adjustments. These adjustments may take days to weeks although they should only take minutes. The pedorthists at Lucky Shoes will make adjustments as many times as necessary on the spot for the patient. I have had great success with this company and continue to use it in my practice.