Orthotic Management for the Foot

Transcription

1 Orthotic Definition Orthotic Management for the Foot Michael Barnett Jr., MD Assistant Professor of Orthopaedic Surgery Boonshoft School of Medicine Wright State University Devices placed inside shoe Accommodative Cushions feet/absorb impact/reduce ground reaction forces Reduces sheer stress Redistributes pressure Functional Biomechanical control of motion/instability Applies force to change position Compensate for foot defects or limb length deficiencies Orthotics Do not correct abnormalities permanently! Common misperception of patients Do not prevent abnormalities Will not prevent you from getting a bunion However, they can be very effective in treating patients who do not wish to have surgery Materials Cross linked polyethylene foam Plastazote Polyurethane foam Spenco Viscoelastic polymers and silicones Semirigid materials Cork, polypropylene Rigid materials Carbon epoxy resin Considerations in Selecting Materials Primary diagnosis Sensory loss? Level of activity Weight of patient Shoe or boot style Over the counter Cost Work well for milder problems Cheap Custom Expensive $$$$ Abused in past Insurance not paying Work well when indicated

2 Rigid Difficult to tolerate in many No shock absorption Acrylics, carbon fiber Do not use in impaired sensation Types Semirigid Most commonly prescribed Strong enough to hold position Soft enough to be comfortable Thicker than rigid inserts Need shoes where insert comes out Types Soft Not good at realigning deformity Great cushioning Great shock absorption Accommodative Types 2001 OITE Which of the following shoe insert materials has the greatest shock absorbing properties? Cross linked polyethylene foam Common Foot Conditions Symptoms Medial Pain Behind medial malleolus Navicular Lateral Pain Sinus tarsi Instability Wearing down shoes

3 Loss of medial arch Heel Valgus Forefoot Abduction with uncovering of talus If deformity is flexible and correctable in your hands Mild Off the shelf orthotics for arch support Moderate Custom semirigid orthotics Neutral heel Increase medial arch

4 Severe Hinged AFO Maintains ankle motion while supporting arch, aligning hindfoot 2001 OITE 70 y/o female has a flexible pes planovalgus deformity as a result of posterior tibial tendon insufficiency. Symptoms improved with cast immobilization but returned when cast removed. Management now should consist of Custom molded orthosis Past Self-Assessment Exam Which of the following orthoses best relieves symptomatic hyperpronation of the feet in a patient who runs recreationally Semi-rigid orthosis with a medial arch support Symptoms Variable Cavovarus Associated conditions Peroneal tendon tears/tenosynovitis/instability, recurrent ankle sprains/instability, ankle/hindfoot arthritis, ankle/metatarsal stress fractures, painful calluses/ulceration, etc. Cavovarus Cavovarus

5 Coleman Block Heel corrects to neutral = FLEXIBLE BUT, now first ray driving in to ground Why treat? Cavovarus Semirigid full length orthotic Lateral heel wedge Lateral forefoot posting or recess first ray Accomplishes the same thing Remember, if deformity is rigid, then not a good candidate for orthotics Off the shelf Donjoy Made for subtle cavus deformities ArchRival 2004 OITE Posting of the lateral heel and lateral forefoot is appropriate for Flexible cavus foot

6 2005 OITE An orthosis that would best address the deformities that are characteristic of Charcot- Marie-Tooth disease would post the Lateral forefoot and the lateral heel. Subtalar Arthritis UCBL (University of California Biomechanics Laboratory) Molded hinged AFO UCBL Rigid plastic From below ankle to midfoot Places heel in neutral Restricts hindfoot motion Completely within shoe Richie brace Custom foot insert attached to medial and lateral uprights Hinged ankle Non articulated AFO Gauntlet (Arizona) brace Plastic shell sandwiched between layers of leather Ankle Arthritis Arthritis at the 1 st MTP joint Pain Stiffness Loss of dorsiflexion Dorsal exostosis Hallux Rigidus

7 Soft leather upper Large toe box Rigid sole Carbon fiber plate under first ray Rocker bottom shoe Avoid high heels Hallux Rigidus Causes increase pressure/painful callosities Tip of toe PIP joint Claw/Hammer Toes Claw/Hammer Toes Hammer Toe Crest Accommodate with wide, deep toe box Watch seams Soft leather upper Hammer toe crest Gel toe caps Gel Toe Caps Metatarsalgia Pain directly under the metatarsal heads Most commonly 2nd Pebble in shoe or sock bunched up Causes Relative short first metatarsal Bunion Long second metatarsal Hammertoe Cavusfoot

8 Metatarsalgia Metatarsal pads Custom orthotics with metatarsal relief Shoe modifications Metatarsal bars Metatarsal bar Metatarsal relief pad Plantar Fasciitis Gel Heel Cups Always check for abnormal biomechanics Cavovarus vs. pes planus Treat with appropriate orthotic Heel cups May benefit some Elevate heel so may actually worsen equinus Keep them stretching Plantar Ulceration Distal Ulceration Location Distal IPOS shoe Proximal Pressure relief shoe IPOS Shoe Possible TCC

9 Proximal Ulceration Charcot Arthropathy Pressure Relief Shoe with removable segments to relieve pressure points 3 Stages I Fragmentation Erythematous, edematous Total contact casting II Coalescence Edema, erythema decrease Bony consolidation occurs CROW III Consolidation Remodeling of bone occurs Custom accommodative orthosis Charcot Arthropathy Charcot Restraint Orthotic Walker (CROW) Used in stage II to prevent progression Bivalve design Easy don/doff Rocker bottom Plastazote insert to reduce shear stress Charcot Arthropathy for stage III Accommodative insert for residual deformity Plastazote liner reduces sheer stress/dissipates forces Extra wide/depth shoes