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Richard; Inserts for high arches and supinator

Posted by AnnabelM on 11/06/00 at 16:41 (032095)

Message Number 32096
Gastrocnemius View Thread
Posted by Kathleen F. on 11/06/00 at 16:42


Message Number 32097
Re: ESWT Progress View Thread
Posted by Barbara TX on 11/06/00 at 16:44


Heidi - Let me clear up your confusion. The achilles tendonitis is not a side effect of the treatment that I had (orbasone, not ossatron), but an effect of beginning to walk normally on my heel again after walking on my toes for so long. I had the same symptoms before I had ESWT and they are not related to it - the site of pain is different. I belive that the AT is caused by a too-rigorous stretching regimine. To my way of thinking, getting it all over in one zap is the most convenient, and even if the treatment site is larger doesn't that cut down the possibility of missing it altogether? I really don't want anyone reading your posts or mine to gather that the AT is a direct effect of getting ESWT. The only way to compare the effectiveness of high and low treatments is to look at the stats on the ESWT board, folks. Thanks, B

Re: Richard; Inserts for high arches and supinator

Richard, C.Ped on 11/07/00 at 07:45 (032156)

Good morning Annabel. I see many different types of feet at my office. I do have people with high arches come quite often. With high arches, soft orthotics will collapse very quickly. I had to learn this from personal experience. Are your hard orthotics made of fiberglass or any other hard plastic material? If so, the problem with those is that they do not provide the proper intimate fit that is required for any orthotic to work properly. I have people come to me that are currently wearing the hard plastic stuff. After I make a cast of their foot, I like to take their current insert and place it on the cast. As of yet, I have not had a time when the orthotic fit the cast. There were huge gaps in the arch. Sorry for the rant, let me continue. I had one patient recently. He is an open volleyball player (one who plays for money), so he is VERY serious about his feet. He has high arches, supinates, as well as having a dropped first ray. He wears out the lateral sides of his shoes, and wears a hole in his shoe at the ball of his big toe. The physician wrote a prescription for orthotics with a metatarsal pad and lateral wedge. In his case, it worked great. I made the insert using the EVA material. To me, this stuff is the best material out there. It give the best intimate fit that I have ever seen. It also holds up for long periods of time. In this guys case, he plays v-ball all summer long. He might wear his inserts out in two years. For the average person, the inserts may last 3-5 years, depending on the amount of pounding or hard usage. I am a competative v-ball player as well, but I do not play as much as this guy. My inserts are the same as his and they have lasted over a year already, and I have not noticed any significant break down as of yet.
With your Birks...maybe you could get a shoe repair person to replace the strap with an elastic strap. This might relieve the pressure somehow. Or, you could shave the part of the strap that hurts your bunion a little thinner. Be careful, it may cause the strap to create a hole over time.
I hope this helps,
Richard, C.Ped

Re: Richard; Inserts for high arches and supinator

Dr. Zuckerman on 11/07/00 at 18:19 (032207)

hi,

What is EVA? This type of foot has been hard to get an orthosis that helps and at the same time isn't uncomfortable. Is this a type of plastizoe or poron? I like a cork leather material,but still wears out fairly fast. Would like to try the next cavus foot type with EVA. So please help my patients.

Thanks

Dr. Z

Re: Richard; Inserts for high arches and supinator

Richard, C.Ped on 11/08/00 at 08:17 (032237)

Message Number 32238
Re: Flat feet and shoes View Thread
Posted by Richard, C.Ped on 11/08/00 at 08:29


Message Number 32241
MRI results View Thread
Posted by wendyn on 11/08/00 at 09:07


What do you think of this on my MRI? My doctor does not think it is the source of my pain (since I have pain in both feet and the left one is fine). Would you want to see another MRI done that shows this better?

'.....on the sagittal views, there is a well circumscribed, septated 1 cm ovoid, cystic structure. Unfortunately, the axial and coronal images do not include this abnormality. It appears to sit immediately deep to the middle cuneiform. From its position, this most liekely represents a ganglion, and it is likely exerting mass effect on the medial plantar nerve.

Impression:
Ganglion as described which is likely exerting mass effect on the medial plantar nerve. However, the axial and coronal images which are more optimal for assessment of this have not been extended to inlclude this lesion. If further clarification of the position and origin of this ganglion is necessary before surgery, then repeat axial and coronal T1 and T2 images are recommended.'

Re: Richard; Inserts for high arches and supinator (EVA question)

Donna S on 11/08/00 at 12:24 (032264)

Dear Richard,

Do you need any supporting fill under the arch with the EVA shell, or is the 1/8 EVA strong enough not to collapse? Are there different densities, or firmness of EVA, and what do you use?

I have almost the identical foot as the volleyball player that you described, along with sesamoiditis under my right big toe. (minor plantar flexed first ray). I now have bilateral PF. Before I got PF my only problem was general metatarsal pain which I had for years, and also some sesamoidits which developed over the last year or two, so I had an orthotic made with a thin shell of poly almost like subortholon with a poron arch fill and post, and a spenco/poron top cover. They were pretty comfortable in a soft sneaker as long as the shoe had a very soft heel, but it wasn't supporting my supination, and I think that's when I started developing the sesamoditis.

When I got severe PF, and later some peroneal tendonitis from an injury my feet were hyper sensitive, so my new pod made orthotics out of pink and white plastizote which felt wonderful, and enabled we to start walking again, but they have a very short life, and are very bulky. Now that I'm improving somewhat I would like a a more durable, firmer orthotic, but I like the soft feel. The other orthotic I had was pretty durable, but I'm wondering if the EVA orthotic you speak of would be a little more comfortable, somewhere in between the soft poly shell, and the plaztizote shell.

My pod just refurbished my old soft poly orthotics (that had been made by a previous doctor), which contour perfectly to my feet, and added some lateral wedging which helps me from supinating, but removed the poron arch fill which extended under the heel like a neutral post. They still have the spenco top cover and poron under the forefoot. They don't feel quite as comfortable in the heel now, and not quite as supportive, or cushioned. I think the poron arch fill absorbed more shock. He said he doesn't like poron arch fill because of how it interfaces with the shoe, plus it caused instability in my foot, especially with the poron post. Now there is no post, because he is trying to keep me lower in the shoe. I asked him about EVA, and he said if the density was soft enough to be comfortable that they would not be very durable, and would start to deform day by day. That's why I was wondering what density that you use.

His goal is to eventually get me out of orthotics once the PF is resolved. I am receiving PT with a lot of calf work, and wearing night splits, which is helping the PF tremendously. He feels the sesamoiditis will resolve itself as my peroneals get stronger, and I stop supinating as much, which he says then causes me to roll back into the big toe. I asked him about about a cut out under the big toe, or a kinetic wedge, but he said he is trying to avoid that, because I may start to pronate onto the bit toe joint.

I don't know if I can ever really go without some type of orthotics, because of the forefoot problems I've always had, even if the PF gets resolved. Have you ever used a met bar instead of a met pad to relieve metatarsal pressure? What is your protocol for sesamoiditis/ and or metarsalagia? Even before I had sesamoiditis and PF the ball of my foot always hurt (not much fat uder balls of foot) unless I wore a shoe with an extremely soft forefoot, mostly very selective sneakers with gel, air, or a very soft eva in the forefoot. With PF, I need a more stable shoe, and its hard to find a neutral sneaker with a very soft forefoot that is very stable. I would also like to wear a casual normal shoe once in a while, but most kill me under the ball of the foot. I also think high arches cause most of the weight to go to the heel and forefoot.

I'm sorry this post is so long, but I'm trying to find the right material that is soft yet supportive, and helps relieve the problems associated with a high arch and PF. Have you ever used a soft flexible poly shell with a fill? Lastly, have you ever used forefoot lateral wedging? My wedge only extends to the midfoot part of the orthotic

Re: Richard; Inserts for high arches and supinator (EVA question)

Richard, C.Ped on 11/08/00 at 13:50 (032272)

Hi Donna,
Wow, your post is as long as most of my answers:-). Just kidding! Well now....I do use the 1/8' shell only to allow room for the toes within the shoe. There are some thicker materials out there, but this is what I like. Yes, there are different densities of the EVA. I don't use the 1/8' alone. I first form the 1/8' to the cast. When that is done, I then cut, cement, and form the EVA 'posting' to the cast. I use different densities (or durometers) for different conditions. For someone very active that has never used custom inserts before, I would start off with a 40 durometer posting. This is pretty soft and is great for someone to get used to wearing inserts. After becoming used to the inserts, I would then grind off the 40 durometer then add a 60 durometer. 60 is wonderful. You get a great rigid orthotic with a wonderful intimate fit to the foot, and it will not break down quick at all. I like to switch from 40 to 60 because the 40 breaks down very fast. I found this out by personal experience. My 40's broke down on me within 3-4 weeks of serious volleyball use. After this happened, I called all the customers I used the 40 on, and added the 60 free of charge. Anyway, I agree with your physician, the softer stuff will break down quicker.

We do have certain protocals for different conditions. I will always speak with the physcian before I do any 'special' work. The physicians I deal with day in and day out tell me that I do not need to call because they trust what I do. I like to call anyway. I have used met bars and pads. I have used wedges and lifts. I have used cutouts along with visco elastic polymer. I only do this with the permission of the physician.

It sounds to me that you have found a physician that really knows his stuff and cares about you. That is wonderful! I do come across physicians that like certain materials, only because they are not familiar with the system and materials I use. When I go 'marketing' to new physicians, I like to crush their feet in a foam box and make them a pair of inserts. This way, they can see and feel exactly what their patients will be using. It is also cheaper than providing lunch for the whole office. Almost always, the physician likes my stuff. Sometimes, they still want to use what they are used to. No problem.

I hope this answered your question. If not, yes, there is wonderful support under the arch in my EVA orthotics. :-)
Richard

Re: Richard; Inserts for high arches and supinator (still a little confused)

Donna S. on 11/08/00 at 15:11 (032275)

Dear Richard,

Thanks for reading my long post.

I guess I'm confused about what your definition of posting is. I thought that only material under the heel portion of the orthotic was considered to be the post, which was to stabilize the rearfoot. My question is do you post just under the heel, or extend it under the shell of the orthotic for support? This is what I mean about 'fill'.

Also, what densitiy EVA do you use for the basic 1/8 shell? Does it also have some give? The reason I'm asking is I tried an EVA orthotic in a specialty running store once, and it was hard as a rock. I'm very interested in this EVA, because I think my feet are still too tender for even soft flexible plastic at the moment, but as I mentioned before the pink and white plastizote deforms too quickly. Also, I asked my pod about black plastizote as a basic shell, because I thought it would be a little firmer, and he said that it was very hard. Have you ever used it?

Re: Richard; Inserts for high arches and supinator (still a little confused)

Richard, C.Ped on 11/08/00 at 15:39 (032277)

Hi again,
Black plastazote is very hard. I have used it on rare occasions. The material on the bottom of the orthosis is usually called posting. The orthosis can be posted with wedges, lifts or anything that the physician requires to aid in healing. My posting extends just proximal of the met heads.

The EVA shell is around 55-60 durometer. It holds up great while providing cushion.
Richard

Re: Richard; Inserts for high arches and supinator (Thank you)

Donna S. on 11/08/00 at 21:11 (032324)

Richard,

Thank you very much for your info.

I think I'll ask my pod if he would consider a pair made of EVA. He's not only a caring gem of a podiatrist, and a biomechanical expert/genius, he also has his own lab, and he makes all the orthotics himself. I feel very fortunate to have found him, and can't imagine what state my feet would have been in right now without him. He's also encouraging my input on different materials. It may be a lot of trial and error to find the ultimate orthotic material, or combination of materials, but he's willing to work with me until I find it.

I just think it's impossible to be familiar with every material on the market, and as you said sometimes doctors stick with certain materials, because that is what they are comfortable with. He is very open to suggestions, because my foot is the one who is wearing the orthotic

Re: Richard; Inserts for high arches and supinator (Thank you)

MattP on 11/09/00 at 02:21 (032342)

Hi Donna S,
Who is your podiatrist that you mentioned? What city and state is he at?

Re: Pod is in San Francisco

Donna S. on 11/09/00 at 07:12 (032343)

Hi Matt,

My Podiatrist is in San Francisco, Ca. I would need to ask him if it's OK to publish his name on the board. He probably wouldn't mind, but I'd feel better asking his permission. He has a wonderful personality, but is very modest. I'll probably see him next week. If you need to know sooner let me know. I can always email you otherwise.

Hint: He's very well know in podiatry and biomechanical circles, because he invented an Inverted Orthotic (othoses) for severe pronators which is used through out the world. I've never seen it, because I over supinate

Re: Richard; Inserts for high arches and supinator (Thank you)

Richard, C.Ped on 11/09/00 at 07:52 (032345)

You are very welcome. I hope this helps in some way. I stand behind the EVA because I and my patients have had great success with them. But you are right, it is your feet and you have to wear them. I am so glad you found a physician that cares so much about you!
Richard

Re: Richard; Inserts for high arches and supinator

Richard, C.Ped on 11/07/00 at 07:45 (032156)

Good morning Annabel. I see many different types of feet at my office. I do have people with high arches come quite often. With high arches, soft orthotics will collapse very quickly. I had to learn this from personal experience. Are your hard orthotics made of fiberglass or any other hard plastic material? If so, the problem with those is that they do not provide the proper intimate fit that is required for any orthotic to work properly. I have people come to me that are currently wearing the hard plastic stuff. After I make a cast of their foot, I like to take their current insert and place it on the cast. As of yet, I have not had a time when the orthotic fit the cast. There were huge gaps in the arch. Sorry for the rant, let me continue. I had one patient recently. He is an open volleyball player (one who plays for money), so he is VERY serious about his feet. He has high arches, supinates, as well as having a dropped first ray. He wears out the lateral sides of his shoes, and wears a hole in his shoe at the ball of his big toe. The physician wrote a prescription for orthotics with a metatarsal pad and lateral wedge. In his case, it worked great. I made the insert using the EVA material. To me, this stuff is the best material out there. It give the best intimate fit that I have ever seen. It also holds up for long periods of time. In this guys case, he plays v-ball all summer long. He might wear his inserts out in two years. For the average person, the inserts may last 3-5 years, depending on the amount of pounding or hard usage. I am a competative v-ball player as well, but I do not play as much as this guy. My inserts are the same as his and they have lasted over a year already, and I have not noticed any significant break down as of yet.
With your Birks...maybe you could get a shoe repair person to replace the strap with an elastic strap. This might relieve the pressure somehow. Or, you could shave the part of the strap that hurts your bunion a little thinner. Be careful, it may cause the strap to create a hole over time.
I hope this helps,
Richard, C.Ped

Re: Richard; Inserts for high arches and supinator

Dr. Zuckerman on 11/07/00 at 18:19 (032207)

hi,

What is EVA? This type of foot has been hard to get an orthosis that helps and at the same time isn't uncomfortable. Is this a type of plastizoe or poron? I like a cork leather material,but still wears out fairly fast. Would like to try the next cavus foot type with EVA. So please help my patients.

Thanks

Dr. Z

Re: Richard; Inserts for high arches and supinator

Richard, C.Ped on 11/08/00 at 08:17 (032237)

Message Number 32238
Re: Flat feet and shoes View Thread
Posted by Richard, C.Ped on 11/08/00 at 08:29


Message Number 32241
MRI results View Thread
Posted by wendyn on 11/08/00 at 09:07


What do you think of this on my MRI? My doctor does not think it is the source of my pain (since I have pain in both feet and the left one is fine). Would you want to see another MRI done that shows this better?

'.....on the sagittal views, there is a well circumscribed, septated 1 cm ovoid, cystic structure. Unfortunately, the axial and coronal images do not include this abnormality. It appears to sit immediately deep to the middle cuneiform. From its position, this most liekely represents a ganglion, and it is likely exerting mass effect on the medial plantar nerve.

Impression:
Ganglion as described which is likely exerting mass effect on the medial plantar nerve. However, the axial and coronal images which are more optimal for assessment of this have not been extended to inlclude this lesion. If further clarification of the position and origin of this ganglion is necessary before surgery, then repeat axial and coronal T1 and T2 images are recommended.'

Re: Richard; Inserts for high arches and supinator (EVA question)

Donna S on 11/08/00 at 12:24 (032264)

Dear Richard,

Do you need any supporting fill under the arch with the EVA shell, or is the 1/8 EVA strong enough not to collapse? Are there different densities, or firmness of EVA, and what do you use?

I have almost the identical foot as the volleyball player that you described, along with sesamoiditis under my right big toe. (minor plantar flexed first ray). I now have bilateral PF. Before I got PF my only problem was general metatarsal pain which I had for years, and also some sesamoidits which developed over the last year or two, so I had an orthotic made with a thin shell of poly almost like subortholon with a poron arch fill and post, and a spenco/poron top cover. They were pretty comfortable in a soft sneaker as long as the shoe had a very soft heel, but it wasn't supporting my supination, and I think that's when I started developing the sesamoditis.

When I got severe PF, and later some peroneal tendonitis from an injury my feet were hyper sensitive, so my new pod made orthotics out of pink and white plastizote which felt wonderful, and enabled we to start walking again, but they have a very short life, and are very bulky. Now that I'm improving somewhat I would like a a more durable, firmer orthotic, but I like the soft feel. The other orthotic I had was pretty durable, but I'm wondering if the EVA orthotic you speak of would be a little more comfortable, somewhere in between the soft poly shell, and the plaztizote shell.

My pod just refurbished my old soft poly orthotics (that had been made by a previous doctor), which contour perfectly to my feet, and added some lateral wedging which helps me from supinating, but removed the poron arch fill which extended under the heel like a neutral post. They still have the spenco top cover and poron under the forefoot. They don't feel quite as comfortable in the heel now, and not quite as supportive, or cushioned. I think the poron arch fill absorbed more shock. He said he doesn't like poron arch fill because of how it interfaces with the shoe, plus it caused instability in my foot, especially with the poron post. Now there is no post, because he is trying to keep me lower in the shoe. I asked him about EVA, and he said if the density was soft enough to be comfortable that they would not be very durable, and would start to deform day by day. That's why I was wondering what density that you use.

His goal is to eventually get me out of orthotics once the PF is resolved. I am receiving PT with a lot of calf work, and wearing night splits, which is helping the PF tremendously. He feels the sesamoiditis will resolve itself as my peroneals get stronger, and I stop supinating as much, which he says then causes me to roll back into the big toe. I asked him about about a cut out under the big toe, or a kinetic wedge, but he said he is trying to avoid that, because I may start to pronate onto the bit toe joint.

I don't know if I can ever really go without some type of orthotics, because of the forefoot problems I've always had, even if the PF gets resolved. Have you ever used a met bar instead of a met pad to relieve metatarsal pressure? What is your protocol for sesamoiditis/ and or metarsalagia? Even before I had sesamoiditis and PF the ball of my foot always hurt (not much fat uder balls of foot) unless I wore a shoe with an extremely soft forefoot, mostly very selective sneakers with gel, air, or a very soft eva in the forefoot. With PF, I need a more stable shoe, and its hard to find a neutral sneaker with a very soft forefoot that is very stable. I would also like to wear a casual normal shoe once in a while, but most kill me under the ball of the foot. I also think high arches cause most of the weight to go to the heel and forefoot.

I'm sorry this post is so long, but I'm trying to find the right material that is soft yet supportive, and helps relieve the problems associated with a high arch and PF. Have you ever used a soft flexible poly shell with a fill? Lastly, have you ever used forefoot lateral wedging? My wedge only extends to the midfoot part of the orthotic

Re: Richard; Inserts for high arches and supinator (EVA question)

Richard, C.Ped on 11/08/00 at 13:50 (032272)

Hi Donna,
Wow, your post is as long as most of my answers:-). Just kidding! Well now....I do use the 1/8' shell only to allow room for the toes within the shoe. There are some thicker materials out there, but this is what I like. Yes, there are different densities of the EVA. I don't use the 1/8' alone. I first form the 1/8' to the cast. When that is done, I then cut, cement, and form the EVA 'posting' to the cast. I use different densities (or durometers) for different conditions. For someone very active that has never used custom inserts before, I would start off with a 40 durometer posting. This is pretty soft and is great for someone to get used to wearing inserts. After becoming used to the inserts, I would then grind off the 40 durometer then add a 60 durometer. 60 is wonderful. You get a great rigid orthotic with a wonderful intimate fit to the foot, and it will not break down quick at all. I like to switch from 40 to 60 because the 40 breaks down very fast. I found this out by personal experience. My 40's broke down on me within 3-4 weeks of serious volleyball use. After this happened, I called all the customers I used the 40 on, and added the 60 free of charge. Anyway, I agree with your physician, the softer stuff will break down quicker.

We do have certain protocals for different conditions. I will always speak with the physcian before I do any 'special' work. The physicians I deal with day in and day out tell me that I do not need to call because they trust what I do. I like to call anyway. I have used met bars and pads. I have used wedges and lifts. I have used cutouts along with visco elastic polymer. I only do this with the permission of the physician.

It sounds to me that you have found a physician that really knows his stuff and cares about you. That is wonderful! I do come across physicians that like certain materials, only because they are not familiar with the system and materials I use. When I go 'marketing' to new physicians, I like to crush their feet in a foam box and make them a pair of inserts. This way, they can see and feel exactly what their patients will be using. It is also cheaper than providing lunch for the whole office. Almost always, the physician likes my stuff. Sometimes, they still want to use what they are used to. No problem.

I hope this answered your question. If not, yes, there is wonderful support under the arch in my EVA orthotics. :-)
Richard

Re: Richard; Inserts for high arches and supinator (still a little confused)

Donna S. on 11/08/00 at 15:11 (032275)

Dear Richard,

Thanks for reading my long post.

I guess I'm confused about what your definition of posting is. I thought that only material under the heel portion of the orthotic was considered to be the post, which was to stabilize the rearfoot. My question is do you post just under the heel, or extend it under the shell of the orthotic for support? This is what I mean about 'fill'.

Also, what densitiy EVA do you use for the basic 1/8 shell? Does it also have some give? The reason I'm asking is I tried an EVA orthotic in a specialty running store once, and it was hard as a rock. I'm very interested in this EVA, because I think my feet are still too tender for even soft flexible plastic at the moment, but as I mentioned before the pink and white plastizote deforms too quickly. Also, I asked my pod about black plastizote as a basic shell, because I thought it would be a little firmer, and he said that it was very hard. Have you ever used it?

Re: Richard; Inserts for high arches and supinator (still a little confused)

Richard, C.Ped on 11/08/00 at 15:39 (032277)

Hi again,
Black plastazote is very hard. I have used it on rare occasions. The material on the bottom of the orthosis is usually called posting. The orthosis can be posted with wedges, lifts or anything that the physician requires to aid in healing. My posting extends just proximal of the met heads.

The EVA shell is around 55-60 durometer. It holds up great while providing cushion.
Richard

Re: Richard; Inserts for high arches and supinator (Thank you)

Donna S. on 11/08/00 at 21:11 (032324)

Richard,

Thank you very much for your info.

I think I'll ask my pod if he would consider a pair made of EVA. He's not only a caring gem of a podiatrist, and a biomechanical expert/genius, he also has his own lab, and he makes all the orthotics himself. I feel very fortunate to have found him, and can't imagine what state my feet would have been in right now without him. He's also encouraging my input on different materials. It may be a lot of trial and error to find the ultimate orthotic material, or combination of materials, but he's willing to work with me until I find it.

I just think it's impossible to be familiar with every material on the market, and as you said sometimes doctors stick with certain materials, because that is what they are comfortable with. He is very open to suggestions, because my foot is the one who is wearing the orthotic

Re: Richard; Inserts for high arches and supinator (Thank you)

MattP on 11/09/00 at 02:21 (032342)

Hi Donna S,
Who is your podiatrist that you mentioned? What city and state is he at?

Re: Pod is in San Francisco

Donna S. on 11/09/00 at 07:12 (032343)

Hi Matt,

My Podiatrist is in San Francisco, Ca. I would need to ask him if it's OK to publish his name on the board. He probably wouldn't mind, but I'd feel better asking his permission. He has a wonderful personality, but is very modest. I'll probably see him next week. If you need to know sooner let me know. I can always email you otherwise.

Hint: He's very well know in podiatry and biomechanical circles, because he invented an Inverted Orthotic (othoses) for severe pronators which is used through out the world. I've never seen it, because I over supinate

Re: Richard; Inserts for high arches and supinator (Thank you)

Richard, C.Ped on 11/09/00 at 07:52 (032345)

You are very welcome. I hope this helps in some way. I stand behind the EVA because I and my patients have had great success with them. But you are right, it is your feet and you have to wear them. I am so glad you found a physician that cares so much about you!
Richard