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Prescribing Orthotics for specific Pathologies
At Nmotion Orthotic Lab, we understand that the ultimate success of Orthotic therapy is dependent upon the design of the orthotic to address a particular pathology.
Pathology Directed Orthoses are simple to prescribe using our flexible Nmotion Rx Form. Full descriptions of each modification arel isted in the Nmotion Catalog . The prescriptions can always be modified to meet specific patient needs.
To order an Orthotic as described for any specific Pathology listed below, Simply write the Diagnosis in the Notes: Space on the Rx form and we will add the details.
Achilles Tendinitis / Tendinopathy
Adult Acquired Flatfoot
Calcaneal Apophysitis
Hallux Limitus
Intoeing Gait
Lateral Ankle Instability
Metatarsalgia
Neuroma
Pediatric Flatfoot
Pes Cavus
Posterior Tibial Tendon Dysfunction
Tarsal Tunnel Syndrome
Plantar Fasciitis due to Everted Rearfoot
Plantar Fasciitis due to Forefoot Valgus
Sesamoiditis
Achilles Tendinitis / Tendinopathy – Orthotic Management
Tendinosis – microtears in the tissues in and around the tendon
Tendinitis - inflammation of the tendon
Most cases of Achilles tendon pain is the result of tendinosis. Tendon inflammation (tendinitis) is rarely the cause of tendon pain.
Achilles tendinopathy is a common condition that occurs particularly in athletes and can be difficult to treat due to the limited vascular supply of the tendon and the stress within the Achilles tendon with every step. Evidence indicates that treatment incorporating custom foot orthoses can improve this condition by making the foot a more effective lever in gait. A 2008 study reported between 50 and 100% relief (average 92%) from Achilles tendinopathy symptoms with the use of custom foot orthoses.
Orthotic Treatment
The orthosis for the patient with Achilles tendinopathy should limit heel eversion and subsequent internal rotation of the tibia to prevent an internal twist of the Achilles tendon, reduce tension on the tendon by encouraging early heel lift, and stabilize midtarsal joint motion to provide a more efficient lever for heel lift.
Achilles Tendinitis / Tendinopthy Rx Suggestions
· Polypropylene Shell - semirigid
· Standard Heel Cup
· If the resting calcaneal stance position (RCSP) is everted,
the practitioner should consider changing this to a deep heel cup
· Wide Width
· Standard Cast Fill
· Closer contact with the arch of the foot limits subtalar
joint pronation and heel eversion by preventing midtarsal joint collapse
· Medial Heel Skive – 4mm
· A medial heel skive helps control heel eversion
· 0/0 Rearfoot Post with no Lateral Bevel
· The slightly broader rearfoot post stabilizes the orthosis
inside the shoe. The post is flat (0/0) to facilitate application
of a heel lifEVA Cover to Toes
· Heel Lift – 3mm
Top
Adult Acquired Flatfoot – Orthotic Management
The adult acquired flatfoot (AAF) is a progressive, symptomatic (painful) deformity resulting from gradual stretch (attenuation) of the tibialis posterior tendon as well as the ligaments that support the arch of the foot.
Although the posterior tibialis tendon plays a significant role, this pathology has recently been recognized as involving failure of other interosseous ligaments, such as the spring ligament. Due to the complexity of this pathology, posterior tibial tendon dysfunction (PTTD) is now referred to as adult acquired flatfoot. Severe flatfoot associated with AAF can lead to other problems, such as plantar fascial tension, tendon pain, rearfoot subluxation, and ankle osteoarthritis.
Orthotic Treatment
Foot orthoses prescribed to treat AAF should reduce the excessive pronatory forces acting across the subtalar joint (STJ) axis. The orthoses must be very controlling with significant surface area contacting the foot. The modifications should increase supinatory torque across the STJ axis. Custom foot orthoses are appropriate for treatment in the early stages of AAF (Stage I and II). As this pathology progresses, foot orthoses are not an appropriate treatment and practitioners can consider ankle-foot orthoses (AFOs) for nonsurgical treatment.
AAF Rx Suggestions
· Polypropylene Shell - semirigid
· Deep Heel Cup
· The deep heel cup increases surface area medial to the
STJ axis applying a supinatory torque
· Wide Width and Medial Flange
· A wider distal width combined with a medial flange significantly
increases surface area under the arch. This effectively
supports the arch and limits excessive pronation.
· Standard Cast Fill
· Standard fill is used since many of these patients also have
equinus. If no equinus is present, use minimum fill for greater control.
· Medial Heel Skive – 4mm or 6mm
· The medial heel skive increases force medial to the STJ axis to
reduce excessive STJ pronation and heel eversion. Either a
4mm or 6mm skive is appropriate.
· 0/0 Rearfoot Post
· The rearfoot post helps stabilize the orthosis in the shoe
· EVA Cover to Toes
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Calcaneal Apophysitis – Orthotic Management
Calcaneal apophysitis is inflammation of the calcaneal growth plate that results in pain and disability
Calcaneal apophysitis usually occurs in children ages 10 – 14 prior to fusing of the plate. It can be associated with repetitive stress or with conditions that cause increased tension or traction on the Achilles tendon, such as equinus or excessive pronation.
Orthotic Treatment
The goal of orthotic treatment for the patient with calcaneal apophysitis is to reduce tension or traction on the Achilles tendon and prevent calcaneal eversion to diminish stress on the calcaneal apophysis.
Calcaneal Apophysitis Rx Suggestions
· Polypropylene Shell – semirigid
· Extra Deep Heel Cup – 20mm
· The extra deep heel cup limits excessive heel eversion.
fIt also prevents calcaneal fat pad expansion to improve
cushioning under the heel.
· Minimum Cast Fill
· Tight contact with the arch of the foot (total contact orthosis)
transfers pressure from the heel and onto the mid-arch.
· Wide Width
· A wide orthosis increases arch contact and distributes more
ground reactive force to the midfoot and away from the rearfoot.
· Medial Heel Skive – 4mm
· The medial heel skive creates a greater force medial to the
axis of the subtalar joint helping to reduce excessive subtalar
joint pronation and heel eversion
· 0/0 Rearfoot Post
· The rearfoot post stabilizes the orthosis in the shoe
· EVA Cover to Toes
· Poron Heel Pad
· Provides greater cushion under heel
· Heel Lift – 3mm
· Adding a heel lift to the rearfoot post decreases tension on
the Achilles tendon by plantarflexing the foot at the ankle joint
Top
Hallux Limitus – Orthotic Management
Functional hallux limitus occurs when the hallux range of motion is limited as a result of jamming of the 1st metatarsophalangeal joint.
Hallux limitus most commonly occurs when 1st ray plantarflexion is restricted during gait. Contributing factors to this condition are excessive force under the 1st ray, excessive heel eversion (subtalar joint pronation), or an everted forefoot. Over time, repetitive jamming can contribute to arthritis of the 1st metatarsophalangeal joint (structural hallux rigidus) or formation of a bunion deformity (hallux abducto valgus or HAV).
Orthotic Treatment
To decrease excessive ground reactive force under the first ray and to allow the first ray to plantarflex. The orthosis should be designed to decrease the everted position of the calcaneus when an everted rearfoot is present. In the case of an everted forefoot, the orthosis should support the lateral forefoot (forefoot valgus).
Hallux Limitus Rx Suggestions
· Polypropylene Shell - semirigid
· Standard Heel Cup
· A standard heel cup is generally sufficient. Consider changing
this to a deep heel cup in the presence of an everted heel.
· Wide Width
· The increased surface area under the arch with a wider width
is more effective in preventing arch collapse and plantarflexing the first ray
· Minimum Cast Fill
· An orthosis with minimum cast fill conforms to the arch,
preventing arch collapse and plantarflexing the first ray
· Medial Heel Skive – 4mm
· The medial heel skive increases force medial to the subtalar
joint (STJ) axis to reduce excessive STJ pronation and heel eversion
· Inversion – 2 degrees
· Inversion of the positive cast increases arch height under
the base of the first metatarsal resulting in plantarflexion of the first metatarsal
· Rearpost Post
· The rearfoot post will help stabilize the orthosis in the shoe
· EVA Cover to Toes
· The topcover allows the addition of the reverse Morton’s extension
· Reverse Morton’s Extension
· A reverse Morton’s extension improves first ray plantarflexion
Top
Intoeing Gait – Orthotic Management
Intoeing is defined as an abnormal angle of gait with the toes pointed excessively inward. This commonly occurs in children of various ages. The rotational (transverse plane) pathology producing this deformity can occur at the level of the hip, knee, tibia or foot.
Although there are persistent claims that intoeing will resolve on its own, failure to reduce the transverse plane rotational pathology on the talus can lead to persistent excess pronation issues. Numerous studies have linked the persistence of torsional problems with the development of arthritic changes. Since intoeing is often compensated by excess subtalar joint (STJ) pronation and excess midtarsal joint (MTJ) mobility, it may make sense to prevent the compensation with orthoses in order to prevent future problems.
There is some evidence that orthoses can reduce tripping and prevent compensatory damage to the feet. In one study, using gait plate (orthoses designed to limit transverse plane abnormalities) resulted in a significant reduction in the amount of intoeing and reduced the frequency of tripping. Parental satisfaction was high or very high, suggesting that this intervention warrants further investigation as an alternative to "observational management" for symptomatic intoeing.1
Orthotic Treatment
The orthosis for the child with intoeing gait should limit intoeing in order to increase stability, decrease tripping and prevent pronatory compensation and subtalar subluxation.
Intoeing Gait Rx Suggestions
· Polypropylene Shell - semirigid with gait plate extension
· The shell of the orthosis extends past the 4th and 5th
metatarsal heads, making it necessary for the child to externally
rotate their lower extremity and abduct their feet in order to propel forward.
· Standard Heel Cup
· If the RCSP is everted, prescribe a deep heel cup to control rearfoot eversion
· Wide Width
· A wider width through the arch increases the surface area
under the arch to provide additional support of the midfoot.
· 0/0 Rearfoot Post
· The rearfoot post stabilizes the orthosis inside the shoe
Top
Lateral Ankle Instability – Orthotic Management
Lateral ankle instability originates from a hypermobile and unstable ankle with a history of lateral ankle ligament disruption. This instability leaves the ankle susceptible to further injury.
Numerous studies have shown that foot orthoses play a significant role in the treatment of lateral ankle instability, although the exact mechanism of their function is debated. This pathology specific orthosis is appropriate for the patient who has ankle instability that produces excessive supination of the foot. This can be a complicated orthotic prescription due to the large variety of foot types that demonstrate this problem.
Orthotic Treatment
The goal of an orthosis for lateral ankle instability is to resist excessive supination by applying a pronatory force to the foot.
Lateral Ankle Instability Rx Suggestions
· Polypropylene Shell - semirigid
· Standard Heel Cup Depth
· Wide Width
· A wider width increases surface area contact for better control
· Standard Cast Fill
· Standard fill allows mild pronation
· 0/0 Rearfoot Post with no Lateral Bevel
· "No lateral bevel" increases the rearfoot post contact area with
the ground to increase orthotic stability
· Valgus Extension
· Increases pronatory torque under the metatarsal heads
in order to reduce supinatory torque and can lead to lateral ankle instability
Top
Metatarsalgia – Orthotic Management
Metatarsalgia is plantar pain within one or more of the metatarsal heads, metatarsophalangeal joints, and/or within the surrounding soft tissue structures.
Metatarsalgia generally results from excessive force or loading under the metatarsal heads. Multiple pathologies of mechanical origin that produce pain occur in the vicinity of the metatarsal heads are grouped into this category. Although commonly recognized as a symptom secondary to a more specific pathology, metatarsalgia is often both a symptom as well as a diagnosis. The exact location of metatarsalgia pain is frequently elusive and tends to migrate, often making it intractable. However, the source of the pain must be defined for a successful orthotic intervention.
Excessive eversion of the rearfoot can increase force under the first metatarsal head. This eversion causes first ray dorsiflexion, decreased first metatarsal weightbearing, and increased lesser met weightbearing, particularly the 2nd metatarsal. Long metatarsals, flat metatarsal heads, and fat pad atrophy can also increase ground reactive force (GRF) under selected metatarsal heads.
Many systemic diseases, including the seropositive and seronegative arthropathies, are also commonly associated with metatarsalgia pain. This pain does not originate within the metatarsal area, but the outside force produces problems or a mechanical imbalance affecting the metatarsophalangeal joint area.
Orthotic Treatment
The goal of orthotic therapy is to transfer forces away from the painful metatarsal heads and provide accommodation and cushioning for localized areas, since increased GRF under one or more metatarsal heads can increase metatarsal pain.
Metatarsalgia Rx Suggestions
· Polypropylene Shell - semirigid with no distal bevel
· The absence of distal bevel increases the distal edge thickness
of the orthosis, transferring force from the metatarsal heads
to the metatarsal necks.
· Wide Width
· A wider width increases surface area under the arch aiding
in the transfer of force off of the metatarsal heads
· Minimum Cast Fill
· Minimum cast fill produces an orthosis that conforms to the arch
of the foot and gently transfers pressure from the metatarsal
heads to the arch area.
. Inversion - 2°
· Inversion increases the orthotic arch height more effectively
transferring force from the metatarsal heads onto the arch (metatarsal necks)
· Poron Metatarsal Bar
· The metatarsal bar acts to transfer force off of the metatarsal
heads by increasing force under the metatarsal necks and shafts
· Poron Forefoot Extension
· A forefoot extension provides cushioning under the metatarsal
heads to decrease velocity at forefoot contact resulting in
decreased force under the metatarsal heads
Top
Neuroma – Orthotic Management
Morton's neuroma is a swelling of the Schwann cells that surrounds the digital nerve leading to the toes and generally occurs in response to irritation, trauma or excessive motion of the medial column of the foot.
Morton’s neuroma often mimics the symptoms of metatarsalgia. Morton’s neuroma occurs as the nerve passes under the interdigital ligament and most frequently develops between the third and fourth toes. Pressure on the lesser metatarsals often increases in feet with an everted rearfoot. There is some anecdotal evidence that using a metatarsal or neuroma pad to separate the metatarsal heads may decrease pressure on the neuroma. The incidence is 8 to 10 times greater in women than in men.
Orthotic Treatment
Orthoses for Morton’s neuroma should reduce pressure on the painful metatarsal head area by transferring force to a larger area.
Neuroma Rx Suggestions
· Polypropylene Shell - semirigid
· Wide Width
· A wider width through the arch increases surface area under
the arch and limits medial column motion
· Minimum Cast Fill
· An orthosis with minimum cast fill will tightly conform to t
the arch of the foot transferring pressure from the metatarsal
heads to the arch area
· Inversion – 2 degrees
· Inversion of the positive cast increases orthotic arch height,
transferring force off of the metatarsal heads and onto the mid-arch.
· Poron Forefoot Extension
· Provides additional cushion under the forefoot which helps
decrease velocity at forefoot contact resulting in decreased f
orce under the metatarsal heads.
· EVA Cover to Toes
· Neuroma Pad
· This elongated metatarsal pad is designed to be placed
between the affected metatarsal heads in order to separate
the metatarsal heads to decrease pressure and trauma on the digital nerve
Top
Pediatric Flatfoot – Orthotic Management
Pediatric flatfoot is a pathology that is characterized by a low, longitudinal medial arch and everted calcaneus. It is often accompanied by the presence of equinus. Pediatric flatfoot is commonly classified as either flexible or rigid. We focus on the flexible pediatric flatfoot since the fixed nature of rigid pediatric flatfoot does not respond well to functional orthoses.
Orthotic treatment for flexible pediatric flatfoot has been a topic of great debate for decades. While the theory that intervention may mitigate midlife symptoms is currently accepted by many practitioners, it remains unsubstantiated in clinical trials. The question that most practitioners deal with is if and when treatment should be instituted. Assuming the child will simply outgrow the problem, particularly if they are experiencing symptoms, ignores the current well-being of the child and the fact that untreated flatfoot likely contributes to foot pathology later in life.
Based on current evidence, children with symptomatic flexible flatfoot require treatment. The asymptomatic children with flexible pediatric flatfoot who are obese, have extreme hypermobility, or systemic or genetic abnormalities should also receive treatment. No treatment is currently recommended for the child with hypermobile flatfoot who has no symptoms and normal development. Normal development is commonly considered to be the presence of a vertical resting calcaneal stance position by age seven.
Orthotic Treatment
The goal of the prescribed device is to reduce pain and deformity associated with pediatric flatfoot by reducing the excessive pronatory forces across the subtalar joint. The orthoses must be rigid enough to support and realign the subtalar and
midtarsal joints, while increasing supinatory torque across the subtalar joint axis.
Pediatric Flatfoot Rx Suggestions
· Polypropylene Shell – rigid to semirigid
· Deep Heel Cup
· The deep heel cup increases surface area medial to the
STJ axis, increasing supinatory torque
· Wide Width and Medial Flange
· A wider distal width with a medial flange through the arch
significantly increases surface area under the arch, effectively
supporting the arch and limiting excessive pronation.
· Minimum Cast Fill
· Minimum fill results in an orthosis that conforms closely to
the arch of the foot and provides superior midtarsal joint control
· Medial Skive – 4mm
· The medial heel skive creates a greater force medial to the
axis of the subtalar joint helping to reduce excessive STJ
pronation and heel eversion.
· Inversion – 4 degrees
· Inversion creates tighter control of the medial arch and
applies a varus wedge effect in the heel cup
· 4/4 Rearfoot Post – extra long
· The post acts to stabilize the orthosis in the shoe.
The increased distal length provides more effective stabilization in the midfoot.
Top
Pes Cavus – Orthotic Management
A foot with an excessively high arch.
Pes cavus occurs in up to 15% of the population, of which 60% will develop foot pain (Burns 2005). Common complaints associated with pes cavus include pain under the metatarsal heads and the heel, lateral ankle sprains, and footwear issues. Custom orthoses should be designed to address the pathomechanics of problematic cavus foot based on the evidence in the literature.
Orthotic Treatment
The orthosis for the treatment of pes cavus foot must accomplish several specific goals:
· Increase plantar surface contact area. The overload on the metatarsal heads is a result of limited plantar surface contact due to the high arch and limited ankle joint dorsiflexion. Increasing plantar surface contact with an orthosis ensures that more of the foot is bearing weight in the arch and the metatarsal heads are bearing less weight for less time.
· Resist excessive supination. Lateral ankle instability and a laterally deviated subtalar joint axis (STJ) are frequently associated with high arched feet. This lateral position of the STJ axis results in excessive supinatory torque around the subtalar joint axis. The prescribed orthosis should be designed to resist this excessive supination.
· Resist both excessive pronation and supination forces. Rearfoot instability is an extension of the laterally deviated subtalar axis. However, in flexible pes cavus feet, midtarsal flexibility complicates the later portion of the stance phase of gait. The forefoot pathology produces midtarsal joint supination that leads to excessive pronation of the rearfoot. Some pes cavus feet suffer from both lateral ankle instability at midstance and rearfoot pronation at late midstance. It is essential that the prescribed orthoses is designed to provide resistance to both excessive pronation and supination forces.
Pes Cavus Rx Suggestions
· Polypropylene Shell – semirigid
· Traditionally, orthoses for patients with cavus feet have
been designed to be flexible. However, recent evidence indicates
that a more rigid device more effectively transfers force off of painful areas
· Deep Heel Cup
· A deep heel cup helps control rearfoot instability
· Wide Width
· A wide orthosis increases the surface area contact with the
arch distributing more ground reactive force to the midfoot
and away from the forefoot and rearfoot.
· Very Minimum Cast Fill
· Tight contact with the arch of the foot (total contact orthosis)
transfers force off of both the metatarsal heads and heel and onto the mid-arch.
· 0/0 Rearfoot Post with No Lateral Bevel
· No lateral bevel” increases the surface contact area
and acts to stabilize the orthosis
· EVA Cover to Toes
· Valgus Extension
· A valgus forefoot extension creates a pronatory moment
that counteracts the excessive supinatory moment, resulting in more foot stability
· Heel Lift – 3mm
· Adding a heel lift to the rearfoot post will plantarflex the
talus, allowing some ankle dorsiflextion
Top
Posterior Tibial Tendon Dysfunction – Orthotic Management
Posterior tibial tendon dysfunction (PTTD) is a tendinopathy which may be due to chronic overpronation or overstretching of the posterior tibialis tendon.
Although the posterior tibialis tendon plays a significant role, this pathology has recently been recognized as involving failure of other interosseous ligaments, such as the spring ligament. Due to the complexity of this pathology, PTTD is now referred to as adult acquired flatfoot (AAF). Severe flatfoot associated with AAF can lead to other problems, such as plantar fascial tension, tendon pain, rearfoot subluxation, and ankle osteoarthritis.
Orthotic Treatment
Foot orthoses prescribed to treat AAF should reduce the excessive pronatory forces acting across the subtalar joint (STJ) axis. The orthoses must be very controlling with significant surface area contacting the foot. The modifications should increase supinatory torque across the STJ axis. Custom foot orthoses are appropriate for treatment in the early stages of AAF (Stage I and II). As this pathology progresses, foot orthoses are not an appropriate treatment and practitioners can consider ankle-foot orthoses (AFOs) for nonsurgical treatment.
PTTD Rx Suggestions
· Polypropylene Shell - semirigid
· Deep Heel Cup
· The deep heel cup increases surface area medial
to the STJ axis applying a supinatory torque
· Wide Width and Medial Flange
· A wider distal width combined with a medial flange
significantly increases surface area under the arch.
This effectively supports the arch and limits excessive pronation.
· Standard Cast Fill
· Standard fill is used since many of these patients also have
equinus. If no equinus is present, use minimum fill for greater control.
· Medial Heel Skive – 4mm or 6mm
· The medial heel skive increases force medial to the STJ
axis to reduce excessive STJ pronation and heel eversion.
Either a 4mm or 6mm skive is appropriate.
· 0/0 Rearfoot Post
· The rearfoot post helps stabilize the orthosis in the shoe
· EVA Cover to Toes
Top
Tarsal Tunnel Syndrome – Orthotic Management
Tarsal tunnel syndrome (TTS) is a painful foot condition in which the tibial nerve is compressed as it travels through the tarsal tunnel producing pain and sometimes numbness distal to the compression.
Tarsal tunnel syndrome generally results from excessive traction or pressure on the tibial nerve. Studies indicate tibial nerve traction increases with eversion of the foot and collapse of the medial arch. This abnormal motion can be minimized by supporting the heel in a neutral or vertical position. Mild ankle plantarflexion and support of the medial arch may also be helpful in reversing the pathomechanics.
Orthotic Treatment
The goal of the orthoses used to treat TTS is to decrease tibial nerve traction by controlling heel eversion, plantarflexing the foot and providing medial arch support.
Tarsal Tunnel Rx Suggestions
· Polypropylene Shell - semirigid
· Deep Heel Cup
· A deep cup helps limit heel eversion
· Wide Width
· A wider width through the arch increases surface area
under the arch preventing arch collapse.
· Minimum Cast Fill
· Minimum cast fill creates an orthosis that conforms closely
to the arch of the foot and helps prevent arch collapse
· Medial Heel Skive – 4mm
· The medial heel skive creates a greater force medial to
the axis of the subtalar joint helping to reduce excessive
STJ pronation and heel eversion
· Inversion – 2 degrees
· Inversion of the positive cast increases arch height in
order to prevent medial arch collapse
· Rearfoot Post
· Heel Lift – 4mm
· The heel lift encourages ankle joint plantarflexion
Top
Plantar Fasciitis due to Everted Rearfoot – Orthotic Management
Plantar fasciitis is a generic term for mechanically induced heel and arch pain.
Plantar fasciitis occurs when tension within the plantar fascia increases. This tension is commonly caused by dorsiflexion of the first ray or supination of the long axis of the midtarsal joint. Calcaneal eversion or compensation for an everted forefoot position (either forefoot valgus or plantarflexed first ray) will cause the midtarsal joint to supinate, increasing tension on the plantar fascia.
Orthotic Treatment
The goal of orthotic therapy for patients with plantar fasciitis due to an everted rearfoot is to decrease tension within the plantar fascia by decreasing calcaneal eversion and reducing the ground reactive force under the medial column of the foot.
Plantar Fasciitis due to Everted Rearfoot Rx Suggestions
· Polypropylene Shell - semirigid
· Wide Width
· A wider width increases surface area under the arch preventing
arch collapse while plantarflexing the first ray
· Deep Heel Cup
· A deep cup limits calcaneal eversion
· Minimum Cast Fill
· Minimum cast fill produces an orthosis that conforms closely
to the arch of the foot and aid first ray plantarflexion
· Medial Heel Skive – 4mm
· A medial heel skive transfers force medial to the subtalar
joint (STJ) axis reducing excessive STJ pronation and heel eversion
Plantar Fasciitis due to Forefoot Valgus – Orthotic Management
Plantar fasciitis is a generic term to describe mechanically induced heel and arch pain.
Plantar fasciitis occurs when tension within the plantar fascia increases. This tension is commonly caused by dorsiflexion of the first ray or supination of the long axis of the midtarsal joint. Calcaneal eversion or compensation for an everted forefoot position (either forefoot valgus or plantarflexed first ray) will cause the midtarsal joint to supinate, increasing tension on the plantar fascia.
Orthotic Treatment
The goal of orthotic therapy for patients with plantar fasciitis due to forefoot valgus is to decrease tension within the plantar fascia by preventing first ray dorsiflexion and allowing first ray plantarflexion. This is accomplished by raising or supporting the lateral forefoot with a valgus wedge.
Plantar Fasciitis due to Forefoot Valgus Rx Suggestions
· Polypropylene shell - semirigid
· Standard Heel Cup
· Wide Width
· A wider width increases surface area under the arch
preventing arch collapse while plantarflexing the first ray.
· Minimum Cast Fill
· Minimum cast fill produces an orthosis that conforms closely
to the arch of the foot and aid first ray plantarflexion.
· EVA Cover to Toes
· The cover allows the addition of a valgus extension
· Valgus Extension
· A valgus extension supports the lateral forefoot decreasing plantar fascia tension
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Sesamoiditis – Orthotic Management
Sesamoiditis is inflammation and pain of the sesamoid apparatus under the first metatarsal head.
Sesamoiditis occurs when repetitive or excessive pressure is placed on the sesamoid bones, eroding the dorsal cartilage and leaving the subchondral bone exposed. Increased pressure and stress at the sesamoids can be caused by an everted rearfoot which drives the medial forefoot into the ground, or an everted forefoot (forefoot valgus). Sesamoiditis pain is often intractable. Effective treatment should reduce stress on the sesamoids which will reduce the inflammatory response.
Orthotic Treatment
To transfer force off of the painful sesamoid(s) to decrease pressure on the sesamoid apparatus.
Sesamoiditis Rx Suggestions
· Polypropylene Shell - semirigid with no distal bevel
· The lack of distal bevel increases the thickness of
the distal edge of the orthosis. This transfers force from the
metatarsal head to the 1st metatarsal neck and the lateral forefoot.
· Wide Width
· A wider width through the arch increases surface area
under the arch, effectively reducing pressure on the metatarsal heads.
· Minimum Cast Fill
· Minimum cast fill creates an orthosis that conforms closely
to the arch of the foot and shifts pressure proximally from
the metatarsal heads to the arch area.
· Medial Skive – 2mm
· The medial heel skive creates a stronger supinatory
moment arm around the subtalar joint (STJ) axis to
reduce excessive subtalar joint (STJ) pronation and heel eversion
· Inversion – 3 degrees Inversion of the positive cast
increases arch height shifting pressure from the first
metatarsal head to the arch of the foot.
· EVA Cover to Toes
· Reverse Morton’s Extension Transfers pressure from the first
metatarsal head and sesamoids to the other metatarsal heads.
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FAQ for Medical Professionals:
What type of orthotics do you make?
Nmotion offers a wide range of custom foot orthoses, from accommodative to functional. Diabetic, Sport, Dress, Fashion, and a variety of everyday use. We are not limited to this popular collection, as a custom lab we are enthusiastic about new ideas and work closely with our clinicians on more challenging projects..
What is your manufacturing process?
Nmotion's
Mmaunfacturing
process
uses
the
latest
automated
technology.
We
can accept cast in any form from digital scans, foam box cast, and
plaster slipper cast. Once a cast is scanned into our automated
software, it is corrected and milled. Depending upon the type of
orthotic prescribed, it may be milled as a corrected positive or direct
milled.
What are things that I can do to assure that my orthoses provide optimum clinical outcomes?
Use evidence-based orthotic therapy by prescribing orthoses based on each patient’s specific pathology. Please refer to our pathology specific infromation page.
How long does it take to have custom orthotics made?
Our data base tracking system ensures a 7 to 10 business day turnaround time, from the day received, rush orders are available at a cost of $25.00 and are then shipped in 3 days.
Adjustments and refurbishments are done and shipped in 3 working days.
Can you manufacture orthotics with my choice of materials?
We offer a full range of orthotics that satisfy most clinicians and patients needs however, we do order in special materials to suit your needs specifically.
How is your lab different than others?
Our goal of efficient friendly approachable service is the key to our success. Nmotion is a custom orthotic manufacturer in every sense of the word. If you can order it, we can build it; We continuously update our "Clinician Preference Profile". This allows us to manufacture orthotics for numerous clinics while maintaining specific preferences. Manufacturing such a wide range gives us an invaluable insight into orthotic therapy options and ideas.
How do Nmotion prices compare to other labs?
Nmotion pricing may surprise you considering our product is superior in quality:
-
One low standard orthotic price (no hidden charges)
-
Numerous styles
-
Additions / Modifications included
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Topcovers / bottom covers included
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Second pair discount
-
Quantity discount
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Subsidized shipping costs
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Attentive technical support
-
Database tracking system
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Volumn accounts can qualify for a free scanning system
Contact us for more details on how you can take advantage of this optimal value.
Billing Codes for Custom Made Prescription Orthotics
Following is a list of currently acceptable insurance billing codes for custom made orthotics and a brief interpretation for your use. Please note, this is only a partial list. For a more complete listing you should refer to the orthotic billing code manual.
L3000
Foot insert, removable, molded to patient model. “UCB” Type, Berkeley Shell, each. Plastic device, molded over model of patient’s foot to provide control of the foot.
This code is used for prescription foot orthotics made of rigid or semi-rigid materials for the purpose of controlling the foot by improving foot function. This can include UCBL devices, modified UCB devices and all rigid or semi-rigid FO’s made from a model of the of the patient’s foot whether plaster, foam or electronic imaging. This code includes all billable fees for the FO including additions such as rearfoot or forefoot posting, padded top covers, soft tissue supplements, balance padding, lesion or structure accommodations and any other additions that may be required.
L3010
Foot insert, removable, molded to patient model, longitudinal and metatarsal support, each. A soft, semi-flexible or rigid device molded over a model of the patient’s foot and placed in the shoe to provide support under the longitudinal arch of the foot.
This code is used for a custom prescription support made on a plaster, foam or electronic image of the foot where no corrections or balancing is performed, providing only longitudinal arch support and no attempt at foot control or improvement of function. Such devices would have a flat heel cup with no heel control, and no posting.
L3020
Foot insert, molded to patient model, longitudinal and metatarsal support, each. A device molded over a model of the patient’s foot and placed in the shoe to provide support under the ball of the foot.
This code is for a custom prescription foot support made on a foam, plaster or electronic image mold of the foot where no corrections or balancing is performed, but additional support is added to enhance or relieve pressure to the transverse metatarsal arch and the longitudinal arch.
L5000
Partial foot, shoe insert with longitudinal arch, toe filler, each.
A5511
For diabetics only, custom molded from a model of patient’s foot, multiple density insert, custom fabricated, each.