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Topics

1st Ray

Sesamoiditis – add at least a sulcus length extension and an accommodation for the 1st metatarsal.

Mortons Syndrome (Short 1st) – add a mortons extension.

Rigid Plantarflexed 1st– cut out the 1st in the shell.

Hallux Abducto Valgus/Bunion – add a slight non bulky extrinsic varus forefoot post to keep patient from pronating too much, and keep the the medial part of the 1st from hitting the ground. Adding a toe spacer between the 1st and 2nd may be tried but does not have the success rate of the past.

Hallux Limitus/Hallux Rigidus- cut out 1st MPJ in shell which should induce plantarflexion of the 1st metahead and improve the range of motion in the MP joint. This option however, will not work in the case where the 1st ray cannot be induced to plantarflex. Another option would be adding a Mortons Extension. Caution should be used with this option that jamming of the 1st MPJ does not happen.

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5th Ray

Plantarflexed 5th Metahead- add at least a sulcus length extension, and add an accommodation for the 5th met.

Styloid Process (5thMetabase)- a prominent 5th metabase-use a pocket accommodation in the shell. For a stress fracture at the 5th metabase you want to splint the area but keep it soft. Do not use an accommodation; instead put a layer of soft padding on the orthotic.

Calcaneal Cuboid Subluxation- add a cuboid pad.

Tailors Bunion- add an accommodation to the 5th metahead.

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Metaheads in General

Intractable Plantar Keratosis (IPK)/Hyperkeratotic Lesions- To accommodate IPKS or other painful calluses, add a sulcus or full length extension with an accommodation to float the affected metahead. To accommodate IPKS on all metaheads use a metabar.

Metatarsalgia- use a met pad, metabar, or metaraise.

Neuroma- use a met pad or neuroma plug in the affected innerspace.

Freibergs Infraction- extend top cover to at least sulcus length and add an accommodation for the 2nd metahead. (3rd if necessary).

Plantar Fat Pad Atrophy- extend device to at least sulcus length and use extra padding in the forefoot and/or the heel as needed.

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Toes in General

Lesions- extend to full length top cover and accommodate at the affected toe.

Hammer Toes/Claw Toes- Rigid Hammer Toe: Add full length top cover and add a toe crest. Flexible Hammer Toe: add a met pad, metaraise, or metabar.

Corns/Calluses- if located between toes, add a toe spacer. Add full length top cover.

Amputated Toes- Usually requires full length top cover, add an amputee sponge fill in. Always send the shoe to the lab for better fit.

Turf Toe- add a full length top cover and a turf toe extension. A turf toe extension is done out of the orthotic shell and limits the motion of the 1st toe MP joint. Shoe is required.

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Forefoot in General

Metatarsus Adductus/In Toe Gait- add a flange to the lateral aspect of the distal plantar surface to induce out toe.

Metatarsus Abductus/Out Toe Gait- control pronation with a flange added to medial aspect of distal plantar surface to induce intoe.

Bursa- place a pocket in shell at the location of the bursa to float it.

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Arch Area

Plantar Fascitis- prescribe the best orthotic to prevent pronation according to the patients weight, activity level, and shoe gear. Some additional things that can be done include: requesting no arch fill, medial flanges, deep heel cups, or arch pads. If the fascia band is tight and sore it may be necessary to place a groove in the orthotic to accommodate the fascia.

Dropped Cuneiform- pocket the 1st metabase in the shell or cut out the 1st ray to the cuneiform. Additionally, an arch pad can be used with a pocket for the 1st metabase to help make the accommodation deeper.
Dropped(or Prominent) Navicular- Prominent Navicular: add a medial flange that extends upward to control pronation and add an accommodation pocket at the navicular to keep the stress of the plastic off of the navicular. Dropped Navicular: add a medial flange that extends outward instead of upward and an accommodation for the navicular. Since the foot is in a fixed pronation position, a flange that extends upward would be painful.

Accessory Navicular (OS Tibialis Externum)  if a navicular accommodation is desired, add a medial flange and pocket the navicular area. However most standard shells would not come in contact with the navicular unless a flange is needed.

Pes Cavus (High Arch)- add no arch fill instruction.

Pes Planus/Pes Plano Valgus (Flat Arch)- add extra plaster fill in the arch area of the cast. If the cast already reflects this low arch area, no plaster fill is necessary.

Tarsal Coalition- order a device that will provide good support for the patients weight, and little to no arch fill on the cast. It is a good idea to pronate the orthotic as it is usually more tolerable to the patient.

Plantar Fibroma- pocket in the shell at the location of the fibroma to relieve any weight bearing pressure.

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Rearfoot Deformities

Heel Spur Syndrome/Heel Spurs- make sure the orthotic is strong enough to support the patients weight and has a good arch to support the fascia. Accommodate with either heel spur pockets, horseshoe pads, or a hole in the shell at the heel.

Calcaneal Apophysitis- it is imperative to request no arch fill in order to support the fascia and to relieve the pull of the Achilles tendon on the calcaneus. Adding a heel lift will also help relieve the pull on the calcaneous.

Haglunds Deformity (Pump Bump) – post the rearfoot of the device the needed amount to limit the pronation. It may be beneficial to some patients to add a flap up the back of the device with a small hole to “float” the Haglund scar tissue.

Achilles Tendonitis: add a heel lift. If it is due to injury you may order the heel lift separate so you can remove it in the future.

Pronation- You can do any or all of the following: medial flange above or below the navicular, post rearfoot in varus, deep heel cup, no arch fill, or reinforce arch with crepe or corax. Note: Above is in descending order of control.

Supination- You can do any or all of the following: lateral clip, post rearfoot in valgus extrinsic, deep heel cup, and lateral heel flare. Note: The above are in descending order of control.

Tibialis Posterior Dysfunction (TPD)- order the Mueller TPD orthotic, or an orthotic with a medial flange and deep heel cup. If ordering the Mueller for heavier patients use a more rigid shell material such as 1/8 or 3/16 Polyproylene.

Subtalar Coalition/Triple Arthrodesis- order a deep heel cup. It is also preferable to get a medial flange and a lateral clip to stabilize the rearfoot as much as possible.

Fixed Rearfoot Varus- order a deep heel cup and invert the device using extrinsic forefoot posting.

Fixed Rearfoot Valgus- order an accommodative device but pay attention to weight so that the device is supportive. Post rearfoot to forefoot, since you are not going to be able to correct the patient’s rearfoot deformity.

Ankle Equinus/Gastroc Equinus- add a heel lift to the device.

Retrocalcaneal Bursitis- cannot accommodate for this condition on the orthotic but you can control pronation.

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Legs and Ankles in General

Limb Length Discrepancy- add a heel lift to the shorter limb.

Genu Varum (Bow-Legged)- use a device that is flat on the bottom and which can also be inverted on top, such as a Balance Support. Additionally, a deep heel cup may be used to help keep the foot seated on the orthotic well.

Genu Valgum (Knock-Kneed)- use an accommodative orthotic with little to no posting correction to accommodate the foot as it sits.

Tibial Varum- use a device which is flat on the bottom, which can also be inverted such as a Balance Support. Additionally, order a deep heel cup to help seat the foot in the orthotic better.

Tibial Valgum- Choose an accommodative device with little to no posting correction. This will bring the ground up to the patients foot as it sits.

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General Foot Diagnosis

Rheumatoid Arthritis- choose a device that will provide the patient with the most support without being too hard. Avoid insensitive foot molds. They will provide immediate relief, but it wont last long due to orthotic fatigue. Use soft padding and a soft top cover while keeping bulk low, such as a soft poron/ultrasuede combination. Finally, accommodate any ulcerations to relieve weight bearing stress. Often accommodations will require a medial extension or a medial flange to reach the area of the ulcer.

Tarsal Tunnel Syndrome- use a device which will provide good control for the patient. The main idea is not to allow the patient to pronate or the medial aspect of the foot to drop.

Rocker Bottom Foot- use an accommodative orthotic with a flat surface on the bottom, such as a Balance Support or a Classic Leather. When the orthotic shell is pressed to the cast, the middle of the orthotic will be sunk while the front and back will be raised. Therefore, the entire surface of the orthotic is contoured to fit this type of foot. The flat bottom of the orthotic allows the patient to wear the device in normal shoes. If there are any ulcers in the arch area, they must be pocketed in the shell.

Splay Foot- Order a device similar to a Heel Stabilizer C. This type has a deep heel cup and medial and lateral flanges that extend distally through the metaheads.

Club Foot/Pes Equinovarus- order a heel lift to bring the ground up to the patients elevated heel. Order no arch fill on the cast. This will help support the patients cavus arch. Finally, request a deep heel cup to help seat the patient’s foot down in the orthotic better.

Drop Foot- Order a Richie Brace®

Diabetic Foot- it is imperative to get a full length soft top cover, such as Nylene, Poron, or plastizote. If the device is to be strictly accommodative, try a diabetic mold. If something more substantial is desired, try a Balance device or Heel Stabilizer out of polypro.

Charcot Marie Tooth Disease- use a polypropylene orthotic that will help stabilize the foot without being too rigid. You may also want to consider a Richie Brace®.

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