2014 CFPM Orthotic modification - CFPM Home · PDF file• Hour glass design • Heel...
Transcript of 2014 CFPM Orthotic modification - CFPM Home · PDF file• Hour glass design • Heel...
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Novel Orthotic Adjustments in the Officeor the Lab
Picture courtesy Jeff Root,Root Orthotic Labs
CFPM Conference, Niagara Falls, ONNovember 6-8, 2014
Private Practice -Whitby & Peterborough, ONProfessor Chiropody Faculty - Michener InstituteCouncil Member - College of Chiropodists of OntarioProfessional Advisory Board - Paris Orthotics
Peter G. Guy B.Sc., D.Ch.
Even the best designed andproperly casted foot orthosesmay require a modification
The inability toperform an in-officemodification canleave yourpatientdissatisfied andwithout their footorthoses.
http://images.huffingtonpost.com/2010-11-15-ANGERSHUTTER1.jpg
Patient satisfaction can be enhancedwhen the appropriate orthoticmodification can be performed inoffice in a timely fashion.
In office modifications will increasepatient satisfaction and outcomes.
The main goal of orthotictherapy is to address thepatient’s foot complaint byreducing the tissuestresses that causes pain.
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“Tissue dysfunction couldbe said to occur when:
1. a healthy tissue isloaded in an‘abnormal’ way,
2. an unhealthy tissue isloaded in a ‘normal’way or worst of all
3. an unhealthy tissue isloaded in an‘abnormal’ way”.
http://thesportsphysio.wordpress.com/2013/09/29/the-myths-of-foot-orthoses-a-guest-article-by-ian-griffiths/
It has been postulated that each of thebody’s tissues has a zone of optimal stressand the tissue must be loaded within thiszone to remain healthy”.
http://thesportsphysio.wordpress.com/2013/09/29/the-myths-of-foot-orthoses-a-guest-article-by-ian-griffiths/Picture courtesy of Kevin Kirby DPM
Mid-tarsal joint
CalfmusclesTibialis posterior m.
Body weight
1st toe joint
The plantar fascia willresist the foot bendingduring heel rise.
Niki: H.N., Ching R.P., Kiser P., Sangeorzan B.J. “The Effect of Posterior Tibial Tendon Dysfunctionon Hindfoot Kinematics.” Foot and Ankle 22:292-300, 2001
Mid-tarsal joint
Calfmuscles
Tibialis posterior m.
Body weight
1st toe joint
Plantar fascia, plantarligaments, and plantarmuscles will stretch whilebones will compress
Foot orthoses are most likely alteringthe forces applied to tissues by…..
1. Altering the magnitude ofthe reaction forces
2. Altering the vector of thereaction forces
3. Altering the temporalpatterns of the reactionforces
4. Altering the plantarlocations of the reactionforces acting on the foot.
Orthotic reaction forces appear to affectthe muscle reaction forces
Or there maybe a neuromotor response between afferent inputand efferent output due to the mechanical orthoses reaction forceacting on the plantar skin via proprioception.
Is Muscle Activity Influenced By FootAnatomy and/or Foot Orthoses?Paris Evening Seminar Fall 2012 ,Christopher MacLean, Ph.D.
The orthotic reaction forces (kineticvariables) are probably achieved viathe following orthotic design features.
• The surface geometry of theorthoses (shape/contour)
• The load-deformationcharacteristics of theorthoses (stiffness)
• The frictional characteristicsof the orthoses (think topcover selection)
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Any orthotic modification weintroduce is changing the surfacegeometry, device stiffness orcushioning
Cast modifications performed at labas per your prescription.
• Expansions
• Fill
• Intrinsic forefootposition
• Heel expansion
• Heel pitch
• Arch contour
• Wedging
Shell modifications performed at the lab• Thickness and
flexibility of material
• Arch flexibility
• 1st ray flexibility
• Arch reinforcement
• Anterior edge length
• Forefoot width
• 1st ray cut out
• Heel post flare
• Heel spur aperture
• Type of post
• Cobra design
• Non beveled anterior edge• Low bulk grind• Hour glass design• Heel seat depth• Heel raise• Sweet spot• Fascial groove
Topcover modifications that can befabricated by the lab or performed inoffice
Type of fabric/material
Thickness
Length
Met. Dome
Preload hallux
Morton’s extension
Reverse Morton’s
Gluing of topcover
Lesion accommodations
Shell Flexibility Tips
Understand the materials you choosealone or in combination
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Postingthe shell
increasesthe
rigidity ofthe shell
The shape of the shell due to patient foottype and heel depth will dictate the flexibilityof the shell.
Simple fix to increase shellflexibility is to lower the heel cupheight
Is the prescribed foot orthotic shankdependent or independentA shank stiffens the shoe underthe arch which makes themiddle portion of the shoe moreresistant to torsion and flexion.
EVA devices are shank dependentas well as most prefabs
http://runblogger.com/images/2012/03/skechers-go-bionic-review-lightweight-zero-drop-and-ultra-flexible-running-shoe-6.jpg
Plastic CFOs are shank independent
The top 5 adjustments requested withinthe first few months after manufacture:
1. Remove/lower met.pads
2. Lower/raise MLA height
3. Extend top cover totoes
4. Reduce shell width to fitshoes / trace / insole/old devices provided
5. Add EVA fill to stabilizedevice/ increase rigidity
List of requested modifications receivedthat could be done in office.
1. Remove RF post/strike plates
2. Trim top cover to matchinsole/shoe provided
3. Increase sidecut/undercut
4. Remove/reduce met pads
5. Hourglass shells
6. Add 1st met cut-out
7. Trim top cover to sulcus ormet’s (from full length)
8. Remove rigid 1st extension
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Some other modifications performed bythe lab on returned foot orthoses
• Shell accommodations (plantar fascia, navicular,fibroma)
• Extrinsic post modifications (skive in heel post,modify motion)
If you talk to a lab owner aboutsuccessful orthotic therapy they willtell you……
Keep it simple !
Casting is Key
Understand your labs arch fill parameters
If you use heel bisections isyour technique standardized
What you need to get started Orange sol™ dissolve it productswill help to remove glue from shell
The Orthotic Modification MatrixMedialColumnOverload
LateralColumnOverload
Increasedmetatarsal headpressure
1st MPJ/raymods
Shoe Volumemods
Misc. mods
AdvancedmedialRF post
5th metcutout
Extrinsic andintrinsic. metraise
Morton’s andReverse’Mortons
Medial RFpost
Buniontopcover
Extendedmedialtopcover
Vertical grindto lateral RFpost
Met pad Plantarfascialaccom
Posteriorheel bumper
Superthotic
Verticalgrind ofRF post
Peronealtendinopathy
Capsulitis/
Plantar plateinjury
Cluffywedge
Heel rimirritation
Bottomcovers
Misc. mods
KirbySkive andInvertedRF
Sometimesan footorthoticwon’t do !
Request distaltopcoverunglued or Preglue shell andtopcover
John Weedor Richiewedgy for ↓ load on PlFascia
Patients whocarry, pushand pull loadson unevensurfaces
Proximalpl.fasciitis/heel spurmod/heelbubble
Cuboid pad ↑ forefoot pressure fromkneeling,stooping orsquatting
The internalmet rocker
Patients whomust stand inplace forlengthyperiods
Morton’sneuromamodification
Acknowledgements Medial Column Overload
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Advanced medial or lateral RF post
• RF post extendedanterior - medially oranterior - laterally intoeither the medial orlateral long arch
• Increased RF controlthrough increasedshell stability andrigidity
Topcover valgus extension with orwithout valgus pad
Extended the topcover medially in theshape of a valguspad will apply a forcevia the shoe upper tohelp createsupination moment.
A valgus pad can beadded under thetopcover. Mitchell, 10 Orthotic Modifications You Can
Perform in the Office Pod Mang Sept 2013
Vertical grinds to lateral RF posteffective control of supination +/- lateralEVA Fill• lateral sidewalls of these EVA
components are groundperpendicular to supportingsurface
• often combined with LateralFlange + Valgus FF postingextended to sulcus
Picture courtesy Jeff Root, Root Orthotic Labs
Medial heel skive and invertedreafoot
Pictures courtesy Jeff Root, Root Orthotic Labs
Heelstabilizer
Heel Skive
Heel skive
Heelstabilizer
Invertedheel
Kirby STJ rotational equilibrium
Pictures courtesy of Kevin Kirby DPM
Medial heel skive Korex modification
Photo courtesy of Larry Huppin DPM
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Medial heel skive with arch fill
Photo courtesy of Larry Huppin DPM
Lateral Column Overload
5th Met Cut-Out
• Shell materialremoved at distallateral aspect ofshell
• Used toaccommodatetailor’s bunion + 5th
MPJ lesions
Peroneal tendinopathy
Pictures courtesy of Kevin Kirby DPM
Lateral heel skive Korex modification
Photos courtesy of Larry Huppin DPM
Sometimes an footorthotic won’t do!47 ♀
Owns landscapecompany
Pain in right ankle forpast two years
Has been advised to gettriple arthrodesisBarefoot gait analysis
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Axial CAT scan R footSlices71 to74 outof 152
Sagittal CAT scan R foot
Cuboid Pad
The cuboid raise is a
very stabilizing and
under-used orthotic
modification for high arch
foot types and
for lateral ankle sprainers.
Jay D. Segel How to Approach Orthotic Modifications Pod Manag, Sept 2010
Increasedmetatarsal headpressuremodifications
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Extrinsic Plantar Met Raise
• Equal offloading from 1st to 5th MT heads by elevatingdistal end of shell
• Since no material is applied to the dorsal aspect ofthe shell, the shell maintains its original MLA profile
3mm EVA applied to plantar aspect ofdistal shell edge and tapered on the dorsalsurface
Intrinsic (within shell) Met Raise
• Leaves distal shell material full thicknesswith no tapering on dorsal aspect
• Creates drop off which will equally offload 1st
to 5th MT heads
• Effectiveness dependent on shell materialselection (not compatible with PRX)
• Maintains the MLA profile of the device
Metatarsal pad to off load painfulplantar metatarsal head
Picture courtesy of Kevin Kirby DPM
Capsulitis or plantar plate injury
Pictures courtesy of Kevin Kirby DPM
Distal End of Topcover Unglued
• Topcover is notlaminated at the distalend of the shell or toany extensions/bottomcovers
• Gives clinician abilityto modify or addcomponents such asmet pads/bars, lesionaccommodations,sulcus crests,neuroma pads
Top cover removed to allow formarking of plantar fibromas. Shellhas pre-glued as well as top cover
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Pre-glue topcovers and shell to allowlesion accommodations
Jobs that involve kneeling, stooping orsquatting require the proximal transferof pressure off of the metatarsal heads
• Minimum cast fill
• Positive cast inversion
• Flexible to semi-flexible polypropylene orEVA
• Non beveled anterior edge or Poronmetatarsal bar
• Deep parabola of anterior edge
• 3-6 mm neoprene or PPT/leather topcover with or without Poron forefootextension to sulcus
• Offloading of any overloaded met.head
1st MPJ/Ray modificationsMorton’s extension andReverse Morton’s extension
Mitchell, 10 Orthotic Modifications You Can Perform in the Office Pod Mang Sept 2013
Plantar fascia accommodation corkonlay
Mitchell, 10 Orthotic Modifications You Can Perform in the Office Pod Mang Sept 2013
Plantar fascial accommodation shellgrind
Photos courtesy of Larry Huppin DPM
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Marking the plantar fascia prior tocasting
Picture courtesy Jeff Root, Root Orthotic Labs
Cluffy™ wedge is helpful when othermethods of getting the 1st ray toplantarflex don’t appear to be effective
Clough Eight Methods of Improving Orthotic Outcomes Pod Mang Sept 2010
The valgus onlay by John Weed is agood in office modification to use to tryto salvage an orthosis that isn’tproviding enough valguscorrection/support in the forefoot
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Picture courtesy Jeff Root,Root Orthotic Labs
John Weed valgus onlay modificationwas used prior to the heel skivemodificationJohn Weed observed somepatients pronated excessivelyoff of their orthoses hetheorized these patients werenot controlled well enoughsince they were pronated atSTJ hence the MTJ wasunstable. He developed thevalgus inlay. The forefoot isdirected into valgus position.
“Richie wedgy” helps to offload theplantar fascia
Use 1/8 inch Korea and skive all three sides except lateral withheight point under mid shaft of the fifth metatarsal.
Pictures courtesy Doug Richie DPM
Sarrafarian Twisted Plate
Sarrafian SK Functional Characteristics of the Foot and Plantar Aponeurosis underTibiotalar Loading Foot & Ankle l 8,(1) 1987
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Valgus wedges reduce the strain onthe plantar fascia
Kogler D.F et alThe Influence of Medial and Lateral Placement of Orthotic Wedges on Loading of thePlantar Aponeurosis. An in Vitro Study J Bone Joint Surg Am, 1999 Oct 01;81(10):1403-13
Case of the Internal MetatarsalRocker
Combination of poly-carbon stiffenerand EVA rocker
Shoe volume modifications
Medial RF post only
• Reduces devicecontrol at heelstrike but maintainsmedial controlthrough midstance
• Reduces devicevolume, ofteneffective in designof dress devices
Lateral half of labstandard extrinsic RF postis removed along withstrikeplate
Posterior Heel Bumper
• 3mm to 6mm EVA wrappedaround heel cup of deviceto advance shell distallywithin shoe
• Full EVA thicknessmaintained at posterioraspect of heel and taperedto 0mm at medial andlateral edges
• Effective when dealing withshoe heel counters whichadvance the heel slightlyforward in the shoe
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Heel rim irritation modifications
Mitchell, 10 Orthotic Modifications You Can Perform in the Office Pod Mang Sept 2013
You can also grind the inside edge ofheel cup rim with dremel burr
Miscellaneous Modifications
Jobs that involve carrying, pushing andpulling loads on uneven surfacesrequire stabilization• High top boots provide most of
stabilization
• Steel shank if using ladders orshovels
• Orthotic device with flat posts,deeper heel cups and wider shell
• 3mm neoprene or Poron/leathertop cover
• Restaurant and retail workerssemi-flexible or flexible device witharch reinforcement along withpadded top cover
Jobs involving standing in place forlengthy periods require offloading fromcalcaneus and metatarsals heads
• Shell to be inversely flexible to thefirmness of the shoe and the surface
• Other factors: foot stiffness, amount ofequinus, weight and age
• Polypro, EVA or Plastazote #3
• Deep heel cups and wide shell withcongruent medial and lateral arch contour,
• Non bevelled anterior edge or met bar
• 3 to 6 mm neoprene or PPT/leather topcover
• In some cases a lower arch with moreshell flexibility is required but may notsuitable for exercise.
Top cover bunion accommodation
Pictures courtesy of Brian Cragg BSc DCh
Superthotic
• Direct milled shell,3mm puff topcoverto toes, agoflexbottom cover totoes
• Useful for devicesused in extremeconditions(temperature/dirt/debris exposure)
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Bottom covers help to stiffen top coversto allow for easy transfer in/out ofshoes
• Agoflex, vinyl, 1.5mm cork/puff bottom covers are effective
• Bottom covers also create sandwich effect at distal end of shellwhich improves component durability via improved lamination
Heel bursitis or heel spuraccommodation
Picture courtesy of Kevin Kirby DPM
A Simple Cure for Morton’s Neuralgia
Journal of the American Podiatric Medical Association Volume 90 • Number 2 • February 2000
Acknowledgments
Brian Cragg
Larry Huppin
Paul Paris
Doug Richie
Jeff Root
Lief Royle
Books by Kevin Kirby DPM thatdiscuss and illustrate orthoticmodificationsKirby KA: Foot and Lower Extremity Biomechanics: A Ten Year Collectionof Precision Intricast Newsletters. Precision Intricast, Inc., Payson, Arizona,1997.
Kirby KA: Foot and Lower Extremity Biomechanics II: Precision IntricastNewsletters, 1997-2002. Precision Intricast, Inc., Payson, Arizona, 2002.
Kirby KA: Foot and Lower Extremity Biomechanics III: Precision IntricastNewsletters, 2002-2008. Precision Intricast, Inc., Payson, AZ, 2009
Book 4 will be out this January
http://www.dpmlab.com/html/bookreview.html
In office modifications will increase patientsatisfaction and word of mouth referrals toyour practice.