Orthotics … Taping … Bracing

Orthotics … Taping … Bracing
Ed Mulligan, PT, DPT, OCS, SCS, ATC
Clinical Orthopedic Rehabilitation Education
Other STJ Neutral Capture Methods
Foam Trays
 Scanning Systems
 Slipper Sock

foam tray casting impression
1. Bottom out the heel with the foot mildly supinated
2. Depress the lateral side of the foot from the base of the 5th
metatarsal to the 5th toe
3. Push the toes into the foam
4. Press the met heads from lateral to medial to the bottom of the foam tray
5. Using the web space of your hand, push the talonavicular area in a posterolateral direction along the STJ axis
Use the “pen” test to check for parallel bottoming out
Starting Position:
The patient needs
is seated so their
knee is at a right
angle keeping the
leg vertical to the
top of the foam
tray.
Do one foot at a time. Position the foot
over top the foam area. Make sure your
patient maintains a right angle in their
leg. Place your finger on their ankle and
find the neutral position
Grasp the ankle with your opposite hand
and push straight down. Be careful not to
let your finger become a part of the
impression. Press firmly down until the
foot is at the lowest point in the
foam. Next, take your finger and press
down each toe until the foot is completely
flat. Remember, do not let the patient
stand in the foam as it will allow the foot
to collapse in the arch and the heel to
rotate.
Carefully Lift their feet from the foam. A
deep impression of the foot should be seen
in the foam. Before you seal the box
remember to enclose the prescription form
that is provided with each tray. Impression
trays can be purchased by the case, each
case contains six self-addressed trays.
Repeat the procedure with the opposite
foot. Remember to push the foot to the
bottom of the foam tray. Each toe and
metatarsal head can be pushed
individually to the trays bottom as well
as the heel and forefoot. Do not allow
the patient to help push down the foam
Scanning Systems

Pedascan
–
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Foot Management’s 2‐D System Xtremity One
–
Podiatry Art’s (PAL) 3‐D System
Digital scanning capture system with on‐line forms and ordering systems
Slipper Socks

Resin‐impregnated slipper sock
–
www.stssox.com for detailed instructions and information
Casting Problems

Anterior tib contraction giving the Steep
Gentle
Flat
appearance of a forefoot varus

Not identifying or holding STJ neutral. Use rule of 1/3rds to recognize appropriate casts 
Flat ‐ gentle slope ‐ steep slope. Does the cast represent the shape of the patient's foot?
Casting Problems

Incomplete or no "loading" of the 4th and 5th metatarsal heads
–
Must dorsiflex the plantar surface of the foot until mild tissue resistance is felt. –
The caster may notice a mild thumb indent from where this loading occurred during casting

It can be punched out after the cast is removed

Excessive loading can be avoided by placing traction at the 4th and 5th met heads once the initial tissue resistance is met
Casting Problems

Proper loading of the forefoot means ensuring that both the 4th and 5th met heads are loaded and the loading is not proximally on the metatarsal shaft or distally on the phalange
Cast Evaluation

Minimal wrinkles

Cast height –

up to the lateral malleolus assists lab in calcaneal bisection but makes it more difficult to remove
Flat dell in calcaneocuboid area with gradual incline beginning 1/3 of the way across the plantar aspect
– Pronated cast – flat dell is larger than 1/3 of the distance
–
Supinated cast – flat dell is smaller than 1/3 of the distance
Ed Mulligan, PT, DPT, OCS, SCS, ATC
injuries typically related to or effected by
pathological hyperpronation

Lower Leg Tendinopathies
–
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posterior tib, anterior tib, peroneal, and Achilles tendinitis
Hallux Abductovalgus
Metatarsal Stress Fractures
Morton’s Neuroma
Plantar Fasciitis
Patellofemoral Syndrome (malalignment)
Anterior Cruciate Ligament Injury
Low Back Injuries
“Podiatric” biomechanical
orthotic therapy
• PURPOSE
− allow the subtalar joint to function near and around its neutral position
•
ACCOMPLISHED by
−
−
balancing the forefoot to the rearfoot
balancing the rearfoot to the supporting surface
orthotic therapy
alternative theories
• Provides a means for medial longitudinal arch support
• Pre‐positions the foot so that as it enters the propulsive phase it minimizes deleterious stresses
• Proprioceptive influence to control the amount and rate of pronation
orthotic indications
1. Support or correct structural deformities of the rearfoot and forefoot
2. Influence, support, or restrict range of motion
3. Treatment of postural abnormalities
4. Dissipate pathological ground reaction forces
5. Decrease shear forces or tender spots on the plantar surface of the foot by redistribution of weight bearing to more tolerant areas
6. Control abnormal transverse plane rotation of the lower extremity
Who really benefits from an orthotic device?
1. Recent IDF changes in ADLs or recreation activities have been minimal
2. Significant navicular drop relative to Feiss line from non‐
weight bearing to weight bearing posture
3. Difficult to detect stiffening of midfoot and/or forefoot when STJ is supinated
4. Structural RF or FF abnormality that causes pathological hyperpronation compensation
orthotic contraindications

Lack of intrinsic or structural foot abnormality
–
–
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i.e. – soft tissue induced equinas (tight Achilles)
Muscle imbalances
Incomplete lower quarter biomechanical examination
orthotic anatomy
•
Module or Shell
− The body of the orthotic that conforms
to the patient’s plantar contours
•
Post
− The “shim” placed on the front or rear
of the shell to bring the ground up to
−
the foot and place the STJ in its neutral position
orthotic types
• Biomechanical
− controls and resists abnormal compensatory foot forces
• Accommodative
− supports the foot
− allows the foot to compensate and yields to abnormal foot forces
− posting is referred to as “bias”
•
Diabetic
−
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total foot contact to disperse weight as evenly as possible on the plantar surfaces
reduce pressure in ulcer prone areas
biomechanical orthotics
 Rigid –
maximal control
–
minimal flexibility
–
normally met head length
–
rohadur, graphite, polypropylene, fiberglass
biomechanical orthotics
 Semi‐rigid
–
partial control
–
semi‐flexible or flexible
–
normally toe sulcus length
–
thermoplastics or cork
accommodative orthotics
 Soft
–
shock absorption
–
normally full length
–
plastizote or PPT
orthotic posting
LOCATION
rearfoot and forefoot
TYPES
tip and bar
ANGULATION
varus (medial angulation)
valgus (lateral angulation)
CONSTRUCTION
Intrinsic‐post within the module
Extrinsic‐post external to the module
Tip Post Bar Post
RF Medial Wedge
RF Lateral Wedge FF Medial Wedge FF Lateral Wedge
FF Bar
Modular Orthotic Systems

www.vasylimedical.com/products/product_a
dditions.html

www.palhealth.com/underdogs.php

www.footmanagement.com/acc.php

www.alimed.com/Alimed/catalog/OrthoticArch-Supports,259.htm
Over-the-Counter Insoles

www.superfeet.com
temporary orthotic demo
primary considerations in selecting an orthotic
• Physiological Age
− not chronological age ‐ older/softer
• Mobility/Restriction Foot Motion
− general foot mobility
− hypo‐normal‐hyper
•
Primary activity for orthotics −
−
sport vs. street
straight ahead vs. pivots
primary considerations in selecting an orthotic
• Chief Complaint/Diagnosis
• specific complaint − need for accommodations
• Control of STJ/MTJ motions
− control vs. bias
•
Shock absorption provided/necessary
−
−
dissipation of ground reaction forces proximal injury primary considerations in selecting an orthotic

Weight of Patient –
–

consider durometer or flex code rigidity and firmness
Neurological or Anatomical Abnormalities −
need for accommodation, top covers, etc
decision making continuum
accommodative
biomechanical
soft
semi-rigid
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age
patient size
motion control
shock absorption
activities
shoes
chief complaint
specific problem
rigid
Orthotic decision
making summary
SOFTER ORTHOTIC RIGID ORTHOTIC
Higher arch
 Stiff foot
 Older Patient
 Support

Lower Arch
 Mobile Foot
 Younger Patient
 Control

orthotic prescription forms
• Patient Information
− Weight, shoe size‐style, activities, occupation
• Product Selection
− type of orthotic
•
Orthotic Instructions
−
Width, forefoot and rearfoot posting
−
“Post to cast and standard RF post”
orthotic instructions
SHELL WIDTH

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Narrow – Ladies dress, bicycling shoes, skates, ski boots
– 5/16” “in” ‐ (normal is 3/16” “in”)
Wide
– Lateral motion sports, children
– Flush with most medial and lateral aspect of 1st and 5th met heads
orthotic prescription forms
• Patient Information
− Weight, shoe size‐style, activities, occupation
• Product Selection
− type of orthotic
• Orthotic Instructions
− Width, forefoot and rearfoot posting
• Extensions (Covers)
−
Materials, length, pockets
• Specialties
−
Specific accommodations
• Comments:
−
General history, diagnosis, specific requests
Met Head Length
Sulcus Length
Full Length
Narrow Grind Street Morton’s Extension Medial Clip
Cobra Pad
Neutral Shell
Heel Lift
Wide Grind Athletic
Lateral Clip
Heel Spur Pad
Dancer’s Pad
Med Pad (Rise)
Forefoot Varus Post
Forefoot Valgus Post
Met Bar
Rearfoot Varus Post
Sesamoid Cut-Out
Rearfoot Valgus Post
orthotic accommodations-modifications
SHELL DEPTH

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Shallow
– Ladies dress or narrow width
Normal
– Casual and athletic shoes
Deep
– High impact athletic shoes
– Increased rearfoot control
shoe selection for orthotic use
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snug, deep, stable heel counter with minimal heel height
adequate shoe depth (toe and heel)
remove insoles and arch cookies
straighter lasts
blucher style throat with at least 3 eyelets for lacing for narrow shank dress shoes must use "cobra pad" –
entire orthotic is posting
generally, athletic shoes and work boots are wider and roomier
to allow better fit and provide more support and control
shoe selection
for orthotic use
• No one orthotic works adequately in ALL shoes
− May need to have 2‐3 pairs or fit the orthotic to the shoe that is used most commonly during symptomatic periods
• Some shoes will not accommodate or are hard to fit with orthotics
− Higher heels
− Narrow shoes (cowboy boots)
orthotic fitting and break-in
• Fit orthotic. Get subjective response.
• Look for static correction of calcaneal position
• Place patient on treadmill or track for 5‐10 minutes
− Check for areas of irritation
− Visualize changes/corrections in gait pattern
• Have patient wear orthotic one hour the first day and increase wear time by 30‐60 minutes/day maximum for each day of wear
• Do not recommend athletic use until tolerated in ADLs for 4‐6 hours.
orthotic labs and services
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types of orthotics available
cost
preferred fitting –
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casting methodology
shipping
additional services
CUSTOMER SERVICE
what labs have you had success with?
Orthotic Labs
Foot Management
7201 Friendship Road; Pittsville, MD 21850
1‐410‐835‐3668
www.footmanagement.com
PAL Health Systems
1805 Riverway Drive; Pekin, IL 61544
1‐800‐447‐0151
www.palhealth.com
LBG Corporate Headquarters
450 Commack Road; Deer Park, NY 11729
800‐233‐2687
www.langerbiomechanics.com
So, does orthotic therapy work?

Yes, only debate is how –
Biomechanical correction?
Root Podiatric Perspective
−
Modification of Tissue Stress? McPoil/Cornwall PT Perspective

Kinematic Change? – “minimizing muscle activity
Benno Nigg
Additional Evidence
of Effectiveness

Orthotics fabricated from STJN were 78% effective
Blake Rl, Denton JA. Functional foot orthoses for athletic injuries: a retrospective study. J Am Podiatr Med Assoc 1985 75(7):359‐362. 
91% orthotic satisfaction rate
Donatelli R, Hurlbert C, Conaway D, St. Pierre R: Biomechanical foot orthotics: a retrospective study. J Orthop Sports Phys Ther 1988;10(6):205‐212. 
93% satisfaction and 95% resolution of symptoms
Moranos J, Hodge W. Orthotic survey: preliminary results. J Am Podiatr Med Assoc 1993 83(3):139‐148. 
Orthotics effective for a variety of conditions
Landorf KB, Keenan A‐M. Efficacy of foot orthoses. J Am Podiatr Med Assoc 2000;90(3):149‐158.
Systematic Review and Analysis
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Orthotics (custom or prefabricated) are effective at preventing first occurrence lower extremity overuse conditions
The cost of prefabricated foot orthotics is low and few adverse effects have been reported (wear discomfort most common)
Individuals typically report decreased lower limb pain with the use of foot orthotics
We have inadequate research to definitively say that orthotics work or not but based on the low risk and potential benefits of this intervention, I believe foot orthotics are an important consideration as part of the treatment of an individual with a lower limb overuse injury
Richter RR, et al, J Athl Train, 2011
Collins N, et al, Foot Ankle Int, 2007
The more poorly something is
understood, the more theories
there will be about it.”
Craig Payne
Department of Podiatry La Trobe University
Bracing vs. Taping
What does the literature tell us about
taping and bracing of the foot and ankle?
Impact on Proprioception/Balance

Seems to improve balance and proprioception but mechanism is unclear
– Conflicting or no evidence for improved peroneal reaction time
– Does not seem to enhance ability to detect inv/eversion movements
Ozer D, et al, Foot, 2009
Refshauge KM, et al, Am J Sports Med, 2009
Shima N, et al, Intl J Sports Med, 2005
Robbins S, et al, Br J Sports Med, 1995
Karlsson J, et al, Am J Sports Med, 1992
Konradsen L, et al, Int J Sports Med, 1991
Impact on Injury Reduction
TAPING NNT BRACING NNT 

No history
26
18
History
143
39
Olmsted LC, J Athl Training, 2004
30 ankle sprains prevented for every 1000 exposures with prophylactic bracing – Jerosch J, Orthopedics, 1996
Fibular repositioning taping decreased incidence (NNT = 22) – Moiler K, et al, J Orthop Sports Phys Ther, 2006
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Semi‐rigid devices significantly reduce injury in those with history of ankle sprains – Handoll HH, Cochrane Database Syst Rev, 2001
Bracing is more effective than taping (or no treatment at reducing ankle injuries – Sharpe SR, J Athl Training, 1997
Impact on Function

Decreases in performance are minor and should not be used as deterrent for prophylactic support
– No substantial effect on agility, sprinting, or jumping
Verbrugge JD, J Orthop Sports Phys Ther, 1996
Beriau, et al, J Athl Training, 1994
–
Does not impair basketball related skills
MacKean LC, et al, J Orthop Sports Phys Ther, 1995
–
Does not negatively impact balance or agility
Paris, J Athl Training, 1992
Impact of Activity on Stability Protection

Taping
– Motion restriction decreases after 10‐20 minutes
Lohkamp M, et al, J Sports Rehab, 2009
–
Sway control diminished after exercise
Leanderson J, et al, Knee Surg Sports Traumatol, 1996
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Bracing
– More effective at restricting motion (immediately and after activity)
Verhagen EA, Sports Med, 2001; Martin N, et al, J Athl Training, 1994

Bracing most effective at limiting inv/eversion and taping most effecting at limiting dorsiflexion
Cordova ML, J Orthop Sports Phys Ther, 2000
Decision

Bracing more comfortable
–
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Stoffel KK, et al, Med Sci Sports Exer, 2010
Bracing more affordable
–
Mickel TJ, et al, J Foot Ankle Surg, 2006
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Bracing more accessible
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Bracing more effective in restricting ROM
–
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Lindley TR, J Athl Training, 1995
Bracing more effective at reducing injury
–
Surve, et al, Am J Sports Med, 1994
Sample Commercial Ankle Braces
Breg – Gridiron
Ultra Ankle Brace
DonJoy Velocity
Kallassy Brace
Swedo
Active Ankle Support
McDavid
AirCast
Bauerfeind
Malleoloc
Spatting
Expensive “fashion” statement or effective means of injury prevention?

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external shoe support produced a significant reduction in the amount and rate of STJ inversion range when healthy subjects were exposed to an unanticipated inversion moment
No change if no tape, better motion restriction and velocity reduction with spatting alone, even better with traditional ankle strapping, and best with strapping + spatting. –
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This was true even after 30 minutes of exercise (although the effect on both dependent variables began to wane) Precaution is that this is only potentially valuable for cleated shoes
–
Spatting definitely alters the frictional stability/resistance to rotational stress in court type shoes
Arch Taping
What does the literature tell us about
arch taping?

Arch (Low‐Dye) taping exerts a biomechanical anti‐
pronation effect
–
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Increases arch height 1‐2 mm that diminishes with exercise
alters neuromuscular activity Franettovich M, et al, Gait Posture, 2010 and Sports Med, 2008
Vicenzino B, et al, Br J Sports Med, 2005
Holmes CF, et al, J Orthop Sports Phys Ther, 2002
Schulthies SS, et al, J Orthop Sports Phys Ther, 1991
Questions?