This PRESENT lecture is brought to you
by the generous sponsorship of
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Foot Pathology-Specific Orthotics
by Paul Scherer, DPM, FACFAO, FACFAS
Chairman, Department of Applied Biomechanics
California School of Podiatric Medicine
Samuel Merritt College
Oakland, California
When we construct orthotics for our patients, we certainly
want to maximize outcomes. Dr. Paul Scherer emphasizes the importance of
constructing a device to meet the needs of the patient's pathology, rather than
prescribing an orthotic to fit the patient's shoe. Surveys suggest that 86% of
the patients are satisfied with the inserts that are made for them. Of these
satisfied patients, to what extent was the problem addressed? What about the 14%
who did not have a good response?. Dr. Scherer challenges us to strive for a
higher level of success.
Dr. Richard Shuster of the New York College of Podiatric
Medicine once said that rolled up toilet tissue placed under the long arch of
the foot will offer some relief to the patient with plantar fasciitis. The level
of success improves as one goes from toilet tissue, to a shoe cookie, to an arch
cushion, to an over the counter insert, and finally to a well made orthotic. Dr.
Scherer's lecture helps us refine our approach to orthotic management.
It all begins with the negative cast. The ultimate goal is a
neutral subtalar joint, a fully pronated midtarsal joint and a stable or plantar
flexed first ray. The "foot type" must be captured in the negative cast if the
orthotic is to have the right shape. Dr. Scherer recommends techniques such as
dorsiflexing the hallux or pulling down the medial column to be sure that the
midtarsal joint is fully pronated during the casting process.
Rigidity of the orthotic is discussed in great detail. The
flexibility of the orthotic is determined by the thickness of the polypropylene
(or other material), the weight of the patient, and if the polypropylene is
vacuum formed or milled. A soft orthotic holding the foot in a compensated
position guarantees failure. A patient with an equinus foot usually cannot
tolerate a rigid orthotic. Dr. Scherer shows us how to titrate the construction
parameters to meet the patient's needs. Consider a "sweet spot" to accommodate
for the displaced navicular tuberosity in a patient with PTTD who needs rigid
control. Use an arch fill to "tighten up" a flexible device, or add poron to the
end of the orthotic to shift weight off the metatarsal heads and on to the shaft
of the metatarsals.
Dr. Scherer also discusses orthotic width, heel cup depth,
posting and top covers. We all tend to accept the notion that subtalar joint
pronation strongly contributes to plantar fasciitis. Dr. Scherer alerts us to
the fact that inversion/supination of the forefoot on rearfoot is actually the
main factor here.
As an added bonus for us, this presentation also includes a
short discussion of the habitual toe walker.
It's always good to discuss biomechanics with our friends on
the West Coast.
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