Custom orthotics have a number of advantages to prefabricated, off-the-shelf insoles, including the ability to modify them. As a result, these panelists talk about the changes that have worked well in their practices and give tips on modification strategy, shoe gear, and material selection.

 

Q: What are the most typical orthotic changes for an intrinsically-posted orthotic device, and why do you employ them?

A:

The uniqueness of how an intrinsically posted device is constructed is highlighted by David Levine, DPM, C.Ped. Clinicians would make cast alterations to the positive model based on the prescription, according to Dr. Levine, in order for the corrections to be mirrored in the orthotic device. In his experience, the easiest changes for intrinsically-posted orthoses are forefoot modifications. However, Dr. Levine points out that in some cases, altering these devices is more challenging.

 

“When problems arise close to the metatarsal heads, intrinsically-posted orthotic devices can be difficult to change or adapt,” Dr. Levine adds.

 

When it comes to this type of equipment, Alan Boehm, DPM, FACFAS, says he is more hesitant. When he wants to obtain a lower-profile option, such as for dress shoes, he usually employs an intrinsically-posted device. According to Dr. Boehm, too much alteration detracts from such trait.

 

Jane Andersen, DPM, agrees, adding that when space is limited in shoe gear, she prefers intrinsically-posted gadgets. The most common adjustment she makes to this type of device is a medial heel skive.

 

Dr. Levine goes on to say that the materials used in an intrinsically-posted device play a big role in its success. Rigid materials, he says, are less forgiving and have a smaller margin of error.

 

Q: What are the most typical extrinsically-posted orthotic device adjustments, and why do you utilize them?

A:

Dr. Andersen says, “By far, the most prevalent (for me) would be a rearfoot post.” “I favor the extrinsic (rearfoot) post because it can better stabilize the device within the patient’s shoe.”

 

A lateral wedge or lateral extension, according to Dr. Boehm, are the most usually used extrinsic alterations.

 

Dr. Levine says, “Extrinsically-posted orthotic devices give the most opportunity for modification.”

 

This form of orthotic, he adds, permits the provider to take more chances while attempting to get more correction. He goes on to say that making a good first impression is the best way to ensure success.

 

Dr. Levine explains, “Device manufacture is fully predicated on making the device adapt to the foot as closely as possible.” “Posting can then be a continuous process.”

 

With an extrinsically-posted device, podiatrists can sand down the posting material and add material under the arch, according to Dr. Levine.

 

Depending on the function of the foot, available range of motion, shoe selection, activity level, and primary concern, integrating elements of both intrinsic and extrinsically-posted devices may be a helpful approach.

 

Q: What are some of the most common forefoot alterations you utilize in your practice, and why do you use them?

A:

Offloading to specific metatarsal heads, kinetic wedges, metatarsal padding, and Morton’s extension are some of the most typical forefoot orthotic alterations in Dr. Boehm’s practice.

 

“I believe a high number of persons with first ray pathology have functional hallux limitus and could benefit from an orthotic adjustment to increase range of motion,” says Dr. Andersen.

 

To do so, she uses a reverse Morton’s extension with a cutout in the shell for the first metatarsal head.

 

Dr. Levine suggests that forefoot changes should be made after the patient has worn the devices for a few weeks. According to Dr. Levine, this gives for a clearer indication of pressure location and how to best relieve this pressure. Furthermore, he claims that this strategy gives the patient and the practitioner time to see what the shoes will allow in terms of material types and thicknesses in the adjustments.

 

A running shoe, for example, will accept a thicker forefoot alteration than a formal shoe, according to Dr. Levine. Furthermore, an older patient with significant plantar fat pad loss tolerates a softer material better than a younger patient with a plantarflexed metatarsal who may tolerate a more stiff material.

 

Q: Do you enjoy utilizing metatarsal pads, and if so, when do you use them?

A:

According to Dr. Levine, the key to success with metatarsal pads is precise placement. He recommends using painter’s tape to lightly adhere a Poron metatarsal pad to the orthotic (which does not get in the way or irritate the foot). This allows the physician or the patient to move the pad about to find the best position before permanently adopting it. If the pad is too distant, for example, the patient may feel an uncomfortable lump without this precision, according to Dr. Levine.

 

According to Dr. Boehm, metatarsal pads are frequently used for neuroma/neuritis discomfort, metatarsalgia, capsulitis, fat pad atrophy, predislocation syndrome, and unloading hyperkeratoses.

 

Dr. Andersen says she’s been using metatarsal pads more in the last five to ten years. She has seen success with them in situations involving neuromas, metatarsalgia, and second metatarsal stress syndrome.

 

Dr. Andersen works as a private practitioner in Chapel Hill, North Carolina. She is a past president of the American Association for Women Podiatrists and an American Board of Foot and Ankle Surgery board-certified foot surgeon.

 

Dr. Boehm practices at Mid-Atlantic Foot and Ankle Specialists in Holly Springs and Raleigh, North Carolina. The American Board of Foot and Ankle Surgery has certified him in foot surgery.

 

Dr. Levine is a private practitioner in Frederick, Maryland, at Foot and Ankle Specialists of the Mid-Atlantic. He is also the owner of New Balance-Frederick and the director and owner of Physician’s Footwear, a certified pedorthic institution in Frederick, Md.