10) Orthotic Prescription Writing Flashcards
Factors to be considered
- Foot type
- Physiological (not chronological) patient age
- Type of activity
- Nature of the chief complaint
- Biomechanical examination
- Shoe style
Cavus foot
- Generally requires softer materials
- Possibly an inverted pouring position for varus heel
Planus foot
- Generally requires more “control”
- Rigid/semi-rigid materials
Children commonly require
- Rigid/semi-rigid materials
- Well tolerated
- Hypermobility is a common complaint
Elderly patients
- Traditionally cannot tolerate rigid materials as well
Sports
- Some element of flexibility in the orthosis
Nature of the chief complaint
- Hypermobility?
- Shock absorption needs?
- Painful lesions?
- Proximal plantar fasciitis?
Biomechanical examination
- Limb length inequality
- FF/RF malalignment
- Transverse plane abnormality
- Pes planus/cavus
- Tibial influence
- RCSP/NCSP
Dress shoes
- Thinner, more rigid materials generally utilized (i.e. TL, graphite)
Athletic shoes
- More orthotic “friendly”
Specialized shoes
- Thinner, more rigid materials generally utilized (i.e. TL, graphite)
Orthoses prescription form contents
- Negative cast pouring position
- Orthotic plate choice
- Forefoot balancing
- Rearfoot posting
- Top covers/forefoot extensions
- Special additions/modifications
Miscellaneous positive and negative cast modifications
- Blake inverted cast technique
- Kirby medial heel skive technique
- Plantar fascial accommodation
- Pronated cast technique
- Forefoot supinatus
Blake inverted cast technique
- A positive cast modification indicated for excessive subtalar joint pronation
- Especially good for runners
- Technique inverts heel of positive cast without inverting the forefoot
- Must include plantar fascial groove
Advantage of Blake inverted casting technique
- Inverts foot without raising arch height
Blake inverted technique measurements
- 5 degrees Blake inversion = 1 degree Rootion inversion
- 15, 25, 35, 45 degrees increments
Kirby medial heel skive technique
- A positive cast modification indicated for excessive STJ pronation
- Reduces dorsiflexory force upon the first ray
Kirby medical heel skive technique measurements
- 2-6 mm generally utilized
- Requires minimum 16 mm heel cup
Kirby medical heel skive technique advantage
- Reduces pronation without inverting foot and increasing arch height
Plantar fascial accommodation
- Indicated when a prominent plantar fascia is present (5 mm standard)
FF supinatus must be
- Casted out
Pronated cast technique is indicated for
- Tarsal coalition (peroneal spasm)
- Rigid pronated foot
- STJ arthritis
- Rearfoot valgus
Pronated cast technique
- Negative cast taken with STJ held in maximally pronated position
Children’s orthosis
- Whitman-Roberts plate: high medial flange/lateral clip
- Heel stabilizers
Orthosis Rx
- Lateral ankle instability
- Interdigital (Morton’s) neuroma
- Posterior tibialis tendon dysfunction
- Sesamoiditis
- Hallux elevatus
- Hallux limitus
Morton’s extension (special addition/modification)
- Firm material to build up directly plantar to the hallux (“bring the ground up to the toe”)
- Not connected directly to the orthotic plate
Morton’s extension indication
- Hallux elevatus
Rigid forefoot extension
- Rigid material is extended directly plantar to the first MTPJ and is connected to the orthotic plate (is an extension of)
Rigid forefoort extension indications
- Painful hallux limitus/rigidus (Kirby heel skive also helpful)
- First MTPJ arthritis
- Unstable MTPJ (s-p turf toe injury)
Hallux limitus is a structral/funtcional deformity with arthritic changes due to
- Long first metatarsal
- Trauma
- Excessive pronation with resulting metatarsus primus elevatus
Functional hallux limitus
- Control STJ pronation
- Unload first ray
- First metatarsal cut-out
- Kirby medial heel skive
- Reverse Morton’s extension
Metatarsal raise (bar, pad)
- Elevation of soft material positioned just proximal to the metatarsal heads (distal aspect of orthotic plate)
Metatarsal raise (bar, pad) indications
- Metatarsalgia
- Interdigital neuroma
Orthosis Rx: Metatarsalgia
- Metatarsal raise
- Forefoot accommodation
Sesamoiditis
- Inflammation of the sesamoid(s)
Orthotic Rx: Sesamoiditis
- Metatarsal raise
- Forefoot accommodation
Orthotic Rx: s-p sesamoidectomy
- Raise of soft material directly plantar to the first metatarsal head
Lateral ankle instability
- Rehab/braces»_space;> orthosis
- High (> 16 mm) heel cup
- Lateral flare to rearfoot post
Lateral ankle instability orthoses reduce the instability by
- Increasing the stability of the forefoot (i.e. forefoot balancing)
Posterior tibialis tendon dysfunction
- Common esp. in obese females
Devices for tibialis posterior tendon dysfunction
- U C B L
- Arizona brace
- Richie brace
- 6 mm kirby medial heel skive
- 2 – 4 degree inverted cast
Cuboid subluxation
- Midfoot pain: “I can walk on my heel or on my toes, but not heel to toe”
- Cuboid pad: 1/8 inch foam/felt
Heel spur syndrome is also known as
- Proximal plantar fasciitis
Heel spur syndrome
- Achilles and plantar fascial stretching is most essential
- Injectable/oral medication
- OTC arch support initially
Plantar fascial strain
- Promoting first ray plantarflexion is most essential to reduce strain upon the plantar fascia
- Valgus forefoot post/extension
- First ray cut-out and forefoot accomodation
- Varus forefoot wedging (posting) increases strain upon the plantar fascia
Peripheral neuropathy
- Plastizote insole
Controlling excessive STJ/MTJ pronation
- Use rigid/semi-rigid materials
- Deep ( > 14 mm heel cup)
- High medial flange
- Flat (0 degrees) motion
- Medial extension to the rearfoot post
- Inverted orthosis
- Kirby medial heel skive technique
Controlling excessive supination
- Lateral flare to the rearfoot post
- High lateral heel cup
- Korex (1/8 in) valgus wedge plantar to 4 & 5 metatarsal heads
Dispensing orthosis
- Proximal to the metatarsal heads
- Contour the patient’s arch with only a small (1/8 – ¼ inch) separation
- Heel should fit entirely within the orthotic heel cup
- Almost as wide as the patient’s foot
Dispensing orthosis evaluation
- Bisect the patient’ heels and observe them standing in the orthosis
- Observe walking with/without
- Success = resupination
Advisories with dispensing orthosis
- Address any areas of irritation, heel slippage, etc.
- Advise patient Orthosis is a brace and may require a period of acclimation (1 hr increase each day)
- Return to clinic in 2 -4 weeks
Troubleshooting orthotic problems
- Heel slippage
- Heel cup irritation
- Arch irritation
- Lateral instability
- Supinatus pain
- Anterior edge irritation
- Orthosis “squeaking”
Heel slipping
- Grind rearfoot post to contact point
- Pad tongue of shoe
- Heel counter pads
- Orthotic / shoe incompatibility
Anterior edge irritation
- Anterior edge of orthotic plate too long (grind)
- Forefoot balance platform applied too proximal
- Inadequate skive of anterior edge of orthotic plate
Heel cup irritation (lateral)
- Inadequate plaster addition to lateral heel
- Inadequate skive of heel cup
Orthosis “squeaking”
- Corn starch powder/cover under orthosis
- Excessive movement within shoe?
Lateral instability of orthosis
- Overzealous correction (inversion)
Arch irritation
- Inadequate plaster arch addition
- Absence of fascial accommodation (?)
- Overzealous correction
Supinatus pain
- First metatarsal pain
- Re-cast for new orthotic device
Arch support
- Direct pressure against the medial arch
Functional orthosis
- Controlled pronation through simultaneous contact of the medial aspect of rearfoot post and medial aspect of the anterior edge of orthotic plate
Movement in RF varus (stages of gait cycle)
- Heel contact = Rearfoot inverted
- FF loading/midstance: Excessive STJ/MTJ pronation limited
- Propulsion: MTJ resupination results in STJ resupination
Correction of RF varus
- If RFV > 8 degrees, post rearfoot 8 degrees inverted with 5 degrees of motion
Good response seen in RF varus correction with these conditions
- Plantar keratomas
- Retrocalcaneal exostosis
- Lateral ankle instability
- Postural fatigue
Variable response seen in RF varus correction with these conditions
- Tailors bunions (symp)
- Adductovarus fifth hammertoes (symp)
- Both depend on 5th ray stability
5th ray is unstable if
- High ( > 8 degrees) 4 – 5 intermetatarsal angle
- Large (> 1 cm) range of motion
- Abduction present upon range of motion
Orthosis with RF valgus will be beneficial only if
- Talus does not contact the ground prior to reaching STJ end range of motion
Good response seen in FF varus correction with these conditions
- Postural fatigue
- Hallux abductovalgus
Variable response seen in FF varus correction with these conditions
- Tailors bunions (symp)
- Adductovarus fifth hammertoes (symp)
- Both depend on 5th ray stability
Marginal response seen in FF varus correction with these conditions
- Plantar keratomas
Problem associated with orthosis for FF varus
- Pronation off the orthotic
FF supinatus considerations
- Heel contact: inverted
- Midstance: excessive STJ/MTJ pronation limited
- Propulsion: MTJ supination results in STJ resupination
- Casting out vs. not casting out
FF valgus considerations
- Heel contact: excessive STJ supination is limited
- Forefoot loading/midstance: excessive MTJ supination is limited
- Propulsion: forefoot (MTJ) pronation limited
Good response seen in FF valgus correction with these conditions
- Postural fatigue
- Plantar keratomas
- Lateral knee strain
- Hallux abductovalgus (symp)
- Tailors bunions (symp)
- Adductovarus fifth hammertoes (symp)
Plantarflexed first ray deformity response of symptoms
- Marginal to poor
- Forefoot has two planes, so plate contact is reduced
