Home The Book Dr Articles Products Message Boards Journal Articles Search Our Surveys Surgery ESWT Dr Messages Find Good Drs video

What do u think of leather and cork?

Posted by Nancy f. on 2/15/01 at 21:36 (039089)

Pleasew help me decide which orthotics would b good for my problem since some drs will try and sell u anything. I have had pf for 20 yrs now with very flat feet. I tried the whole iceing stretching pt route. Now dr suggested cork and leather orthotics semi ridgid. I read here I guess that when fet are really flat u should not have hard plastics for orthotics. Also dont u think I should stand when they take the mold for weight bearing purposes? What about the 6000 machine that is methioned? what is this called. They say u should stand on it to have your gait checked before doing the mold. I am very confused about this ordeal and dont want to waste money so I really am hopeing for some excellent advice. Also how will an orthotic hold up a 200 lb. body? I just got arch aid and I have to say not bad. It compresses the foot and lifts it from the ground. Only 2 days but I thionk i have something good here. please e mail me. i greatly appreciate it 7 look forward to it. nancy

Re: What do u think of leather and cork?

Richard, C.Ped on 2/16/01 at 08:58 (039129)

Hi Nancy,
I am not a fan of leather or cork. We used cork when we first started the business. It was ok, at the time. Through trial and error, I have found that EVA holds up longer than cork. Cork is ok for low impact usage. I just prefer EVA over anything that I have tried. I have treated huge football players over 200 pounds, and their inserts are still holding up very well. The wear them in their everyday shoes as well as football cleats.

I may sound like I am stuck in 'EVA land', but I know the stuff works and holds up very well. I have been send many samples of different materials, and EVA shows the best fit. Cork tends to hold in smells as well. Ewwwww.

I don't like leather either. I can't give you to much of a reason besides it seems 'slick'. I don't like the feel.

I like hard plastic. You can use them as windshield ice scrapers in the winter. You can heat them up and flatten them out to use as table coasters. Great stuff. For an orthosis, nope.

I personally do not believe you can get the best functional orthosis possible by taking a weight bearing impression. Using the Footmaxx or other similar machines will make an ok accomodative orthosis, but I am not a fan of that either.

My personal belief for getting the best cast of your foot is to have a podiatrist who knows what they are doing, use plaster strips in either a semi or non weight bearing position. The second is to use a foam box. Again, the person has to know what they are doing.

Good luck to you. If you have any other questions please feel free to let me know.
Richard

Re: What do u think of leather and cork?

Larry Huppin, DPM on 2/16/01 at 19:32 (039202)

The material is the least important consideration in orthotic therapy. The most important consideration in achieving positive clinical outcomes is the skill of the person who is taking the cast of your foot and writing the prescription.

Given that, every material has advantages and disadvantages. Cork and leather can do the job, but wears out very quickly.

And you are correct, the cast should be non-weightbearing -- as long as the practitioners knows what they are doing. Find yourself a podiatrist with a special interest in orthotic therapy.

Larry Huppin, DPM
Seattle, Washington

Re: What do u think of leather and cork?

Brian G C.Ped on 2/18/01 at 08:21 (039299)

I also prefer eva to other materials, it is easier to mold and spot heat, wears well, and if it is pure eva the device can be washed in antibacterial soap. I have made them for several water skiers and they dont break down or delaminate when wet.

I would say 90% of the 4 to 5 pt I see a week with a bag full of orthotics that are not working are hard plastic. Nothwest Podiatric uses carbon/ graphite with great results, they have it down to a science. It is much more than just a heated and vac formed piece of 1/8 inch material. They lay the fiber up at diff angles to control flex region of device. I use them with great success for skaters and dress orthotics.

I think many practitioners are taught that the device has to be very hard to control foot function, While this may be true for the hypermobile foot, you still can get a great funtional device with eva.

The problem i see most often is the pt that over pronates gets a device that is 3/4 length(not always bad) that has no forefoot correction, and the rearfoot is either neutral or has a weak post. many try to rely on the arch to 'correct' the foot. Many over pronators have tight heel cord. Lack of rearfoot control and some lift causes the midfoot to collapse into the arch of the device at mid stance on.

That in my opinion is one of the reasons I hear 5 times a week 'I tried to wear it for a few weeks and it felt like a golfball under my arch, so i stopped wearing them'

Re: How to find good orthotics

Larry Huppin, DPM on 2/18/01 at 11:08 (039305)

A patient should not be looking for a specific material, but rather for a good practitioner. If correctly prescribed and manufactured orthoses will be comfortable regardless of durometer (hardness) of the material. In fact, a quality practitioner should guarantee orthotic comfort. They will not be able to guarentee complete resolution of symptoms as orthoses are only a part of a total treatment plan, but you should always expect comfort. Ask the practitioner if they guarentee the devices will be comfortable. If not, find another practitioner.

I can never understand why people will simply accept an uncomfortable orthosis and throw it in a drawer, when if they had a pair of eyeglasses that were causing headaches they would head direclty back to the optometrist.

The Northwest Labs graphite is a great material and I use it often for ski boots, dress shoes, etc. But polypropylene is also a great material and somewhat easier to work with. The material is of only minor importance. Orthotic comfort depends on:
1. The cast of the foot
2. A prescription that truly addresses the patient's foot biomechanics and structure
3. The positive cast made by the laboratory
4. The relationship between the shoe and the orthosis

The work that the lab does on the positive cast is critical. For accurate positive cast work consider practitioners that use one of these three labs to manufacture their orthoses:
Northwest (www.nwpodiatric.com)
ProLab Orthotics / USA (www.prolaborthotics.com
Precision Intricast (www.dpmlab.com)

ProLab sends out a weekly e-mail newsletter with extremely helpful hints on improving orthotic therapy. Some people may be interested in signing up for those.

Larry Huppin, DPM
Seattle, Washington

Re: Reply to Dr Huppin How to find good orthotics

Donna SL on 2/18/01 at 20:08 (039351)

Dr. Huppin,

I don't agree that the type of the material used in an orthotic is not an important consideration. I think many people need an orthotic shell with some give to it. You must also consider the foot type. People with cavus feet like myself, or someone with arthritis, or even a flat foot, etc., may not be able to tolerate a semi rigid material for whatever reason, no matter how well the orthotic is made. There are so many wonderful materials out there, that can be combined to make a comfortable, strong, supportive, and controlling orthotic. This type of device of course takes more time, and more skill to make, and requires some creative thought to produce. I think the polypro orthotics that are being offered by most pods are a cheap fast way to produce orthotics. I don't think a 'one type of material fits all' approach can1 be taken. The reason people are seeking the services of Cpeds, orthotist, etc. are because they are willing to keep up to date on state on the art materials, and material synergy for orthoses, and are striving to produce functional comfortable orthoses. I think Pods should be able to give the patient something more comfortable, and offer more options for what they are charging. If you do a search on orthotics on this board you will see many orthotic failures from devices made of rigid to semi rigid material. I'm sure there are many failed orthotics produced from some of the major labs you have mentioned. Can they all be blamed on poor casting, or corrections?

You may be interested this article.

http://www.biomech.com/db_area/archives/1997/9703materials.bio.html

I had several pairs of orthotics made out of the semi rigid polypropylene. The first pair precribed by the first pod were extremely uncomfortable, but I kept trying to break them in. They were also made at one of the big labs you listed. It was one of the worse orthotics I ever had. After many adjustments they still caused much pain, and eventually injuries that I am still recovering from.

I got a second opinion from another pod, who said the first ones hurt, and caused all my injuries, not because of the material, but because they were the wrong prescription for my foot type, and said polypro, should be comfortable with the proper prescription, and offered to make me a new pair. He was also concerned that there may be some permanent damage from the first pair.

As a matter of fact, the first and second pod mentioned above are probably among the finest biomechanic experts in their field (names I know you would recognize). They both took a perfect cast. I had extreme confidence in the second pod who meticulously corrected the cast himself, and then made the orthotic device personally. The new orthotic prescription felt more correct, and helped relieve some of my symptoms, but the material still hurt, and was too hard and rigid, and I could not wear them more than around 20 minutes at the most, without causing pain even after many adjustments. They are sitting in a drawer . I asked if he could make something a little softer, and he went to the other extreme, and made a functional orthotic out of pink and white plaztozote, that were much more tolerable, but a little to soft and bulky, and had horrible durability. They initially helped stabilize my foot comfortably to allow some healing. When they started to break down (which was very quickly) they started causing other problems . I asked if he could make something in between with more durability (EVA, or a multidensity orthoses, etc.), but he wasn't really interested, and said 'those materials are a Cped thing'. I still think he is an excellent pod in the area of biomechanics, but ignorant in many of the other materials available to produce orthoses.

Neither pod guaranteed their orthotics. Most in fact ask for payment up front, and offer no guarantees.. Since the money was already invested, I kept trying to get them to work. I invested a large amount of money, and time, and still do not have a new orthotic to show for it. I have talked with many people who have different foot types than I who experienced similar problems.

Years ago I had an orthotic made a from a very flexible thin polypro supported by a poron arch fill from another lab. I was told later this lab does not do a great cast correction. At the time, it was the most comfortable orthotic I had ever had, and I thought they were a successful orthotic with only some minor problems, that I thought could be corrected. I went to the first new pod listed above, because they needed some refurbishing, and wanted to have a second pair, and the original pod who made these was no longer available. This new pod told me my current
orthotic was no good, and preceded to make the ones that caused injury.

The reason I sought orthotics in the first place was because I have a high arch, and had only some metatarsal discomfort. The semi flexible ones seemed to be the most comfortable, and provided much relief, and never caused any injuries. After wearing the more rigid polypro ones, over a course of a year, I developed a bad case of PF, and severe tendonitis in the heel, most of the foot, and lower extremities.

Just recently out of frustration I picked up my perfectly corrected cast from the second pod, and took them to a orthotist/cped who owns
a small private lab. He is going to make an orthotic out of several different materials. He claims this combination will give both comfort, and durability. It is going to made out of pro xp2, ucolite, trilam, and reinforced with thermal knit, and maybe one other material I can't remember. These are much more expensive materials, and a much more labor intensive orthotics to make, yet he is charging me less than half of what the other orthotics cost. He took a cast himself, and offered to correct it, but I requested that he use my most recent cast from the second pod. He also has a cad/cam system for producing EVA orthotics which he uses on many patients with success, but felt with my foot type I would benefit most from the orthotics created from the traditional non weight bearing plaster cast method with the above listed materials. .

I haven't received them yet. If these don't work with a more forgiving material, I will assume that my foot cannot take a full correction, but will stick with a more accommodative material. If the cast can't be adjusted I would probably seek a new DPM who would take a new cast if necessary, but who would be willing to work with this orthotist/cped.

From the majority of the orthotics I see being produced profit seems to be more important than patient comfort. Most of these large labs offer very
few accommodating materials, and keep producing single density orthotics, other than for the top cover. I feel this is because they are easy, and
inexpensive to produce. They may offer a few of the softer thermoplastics for diabetics for example, but either the dpm's or the labs are not fully utilizing the selection of materials that are out there, in the proper combinations. The semi rigid orthoses may work for some people, but I think in other cases podiatrist should be willing to work as a team with cpeds, orthotist, and the patient in improving orthotic comfort.

I'm still not the same as I was before got injured from the first orthotics, but am around 70% to 80% better most of the time. I can tolerate the original semi flexible ones for a couple of hours now with some additional wedging, but still cannot wear the semi rigid perfectly corrected poly pro ones made from the second pod above, nor do think I ever will be able to.

Lastly , I sometimes think orthotics are prescribed too quickly, when someone comes in with a foot problem, or injury, and they may not be the first line of therapy that should be offered. When I first got injured from the first pair of orthotics, the second pod immediately made a second pair which helped resolve a very small portion of my symptoms. Only after months of trying orthotic therapy, did he finally recommend physical therapy. Only then did my symptoms start to improve dramatically.

Donna

Re: How to find good orthotics

Richard, C.Ped on 2/19/01 at 08:20 (039380)

Good morning Dr. Huppin,
I know that with me, EVA is the most comfortable that I have ever worn. I have experimented with many material on myself so I will know pretty much what the patient is feeling.

About people throwing their orthosis in the drawer. I agree with your example of eyeglasses. Customer service should be top priority. To many people are in it just for the money. I hate that. I really do. I don't know if you have ever read the past posts that some people have written, but for some, it is very difficult for some to get the proper adjustments needed. People have complained that the doc or professional told them that they would get used to it. Some people have told me that their professional allows two adjustments, then they will start charging for them. Some charge right off the bat. I don't do that. If it is not right the first time, I will fix it.

I know that the hard plastic inserts that do not have posting is very difficult to adjust. I have had DPMs write and Rx for me to add posting just so I can interface the orthosis with the shoe. I do question the education and experience of some people that fabricate these things. The work that I have seen can be described as no less that a joke.

I don't do that. If it is not right the first time, I will fix it.

Have a great day,
Richard, C.Ped

Re: Reply to Dr Huppin How to find good orthotics

Larry Huppin, DPM on 2/19/01 at 20:35 (039422)

Donna,

I'm sorry you have had trouble finding comfortable orthoses, but I think you misunderstood my comments. I agree that material is an important consideration when writing orthotic prescriptions - personally I regularly use over 10 different major materials for orthotic fabrication. But material choice is only one portion of an orthotic prescription and not the most important. Casting technique, correction, size, contact, control techniques, shoe recommendations, the amount of deformation during weightbearing, topcover materials, etc., etc. (this list could go on for a couple pages) are all as, or more, important. Given that, every material and combination of materials has inherent advantages and disadvantages. The most important consideration is the knowledge and skill of the practitioner. That's why one of the first questions that should be asked of any practitioners is 'do you guarentee comfort?' No practitioners, regardless of the letters after their name, can guarentee a specific clinical outcome. Orthoses are usually only part of a treatment plan. But if the practitioner is confident and experienced in orthotic therapy, they should guarentee that you will be comfortable in your devices. If you are not, they should be willing to make adjustments, replace them, or refund your money. In my office if we have to make more than 3 adjustments for comfort on any pair of orthoses we reevaluate the situation and start over again. At any point, at the patient's discretion, they may receive a complete refund. I think it is fair for you to ask the same of anyone who is making orthoses for you. If they are excellent practitioners of orthotic therapy they will rarely have to make that refund.

I am very familiar with the article you mentioned. It makes some points I agree with and some that I don't. Keep in mind that it was written by the president of a company that sells the materials mentioned in the article.

There is good, bad, and average in every medical specialty and orthotic therapy is no exception. I hope that this next pair works out for you.

Good luck,

Larry Huppin, DPM
Seattle, Washington

Re: Thanks Dr. Huppin

Donna SL on 2/22/01 at 04:02 (039620)

Dr Huppin,

Thank you for your response the other day. You seem like a very kind and
thorough practitioner, and offer a rare guarantee. It seems reasonable
that after 3 adjustments if the orthotics are uncomfortable, or in my
case caused extreme pain then there is something very wrong with
either the prescription, material or both, and the situation should be
re-evaluated. I now realize , even the most experienced practitioner
can make a gross mistake, and just not understand your foot type.
Unfortunately it is usually at the patient's expense, both physically,
and financially. Office visits and adjustments are charged in addition
to the cost of the orthotics.

Prolab seems to be the lab most used in my area. Does Prolab have
different densities of polypro? It seems like the polypro they used on
a pair that I had made from them a while back was very hard, even at the thinner density. The shell color was clear, or what they call natural. The orthotics I had made at KLM years ago were made from a 3mm polypro, but it seems like a slightly softer plastic. When I push in on it, it has some give to it. Do you know if KLM uses a different type, or are there different durometers of polypro? Also, does Prolab have more materials available then are listed on their web site? (i.e. different densities of EVA, other top covers, etc.) I also inquired about Northwest labs technology once, and a pod said they are difficult to adjust with spot heating.

May I ask what materials, and/or orthotic design you've been successful with for someone like me who has high arches, supinates excessively, causing lateral instability, but has some midstance pronation in one foot, (may be due to mild Planterflexed first ray) and is still somewhat sensitive in the heels, and arch? Have you had any functional orthotics fabricated out of EVA?

Donna

Re: Thanks Dr. Huppin

Larry Huppin, DPM on 2/22/01 at 12:54 (039651)

Donna,

ProLab can make any rigidty of polyproylene - from super flexible to hard as a rock. All the lab does is to fill the prescription of the practitioner who writes the prescription. The practitioner should be aware of what factors affect rigidity - for example, take an orthosis made of 5/32 inch polypropylene. For someone with a very flat arch, this would be an extremely flexible device. For someone with a high arch it would be quite rigid (all materials become more rigid with greater curvature). ProLab does use a very high grade of polypropylene so that the devices last longer - it may be more rigid for the same thickness as poly from other labs. That just allows you to use a thinner poly for the same strength. But even for someone under 100 pounds,, if prescribed correctly you can get a very, very flexible poly device if you wish.

I'm hesitant to answer what material I might use for your foot because there are just so many different factors involved. But, and take this with a grain of salt, here might be a suggestion as a starting point for a high arch:

1/8' poly shell. Left as is, this would be extremely flexible. Actually too flexible ot provide much control. So, we would add an EVA arch fill. This will provide some shock absorbtion and make the device more supportive. But it also gives us the ability to make the device more flexible simply by grinding out some of the EVA. A soft topcover to the toes or sulcus (depending on shoes) for comfort. A wide device is imperative to ensure comfort and control. Also an extension under met heads 4 and 5 extending back under the met shafts will help control the lateral instability. Keep in mind that is not by any means a complete prescription - but hopefully it gives you some idea of the way I might start.

I have done a number of functional orthoses out of EVA and they work fine. My only problem is that if they are pure EVA (with no shell at all) they do not last very long. Like EVA in a running shoe, they will lose much of their resiliency in about 400 miles. As long as the patient is aware of this, they are fine devices.

ProLab has almost every orthotic material available. Many densisties of Plastizotes and EVAs, Poron, Corks, 10 or so topcover materials, etc. They will do whatever the doctor prescribes.

And you heard correctly - NW graphite, while the thinnest material available, is very hard to adjust. As I said, there is no perfect material Each has advantages and disadvantages.

Larry Huppin, DPM
Seattle, Washington

Re: Thanks again Dr. Huppin

Donna SL on 2/22/01 at 19:00 (039679)

Dr. Huppin,

Thanks for your advise. I looked at my old medical records, and a copy of the Prolab order form, and the shell was 5/32 inch poly, with no arch fill. The pair made from the second pod look even thicker, so that's why they must have seemed so rigid to me (I'm only a medium weight). None of the orthotics had any forefoot wedge type extensions.

The Pro-aerobic orthotic from Prolab seems close to your description. I asked the Pod who made the above orthotics once about the Pro-aerobic, and he said they would be more rigid, but I don't think that's the case now. I also just noticed Prolab has a device called Featherweight with a suborthalon shell.

In case the softer material on the current pair I'm waiting for don't seem supportive enough, or breaks down to fast, I would ask whom ever I go to if they would give what you described a try. I'm starting to be able to tolerate my old KlM poly orthotics which have a similiar design. The only difference is there is a poron (enduro) arch fill, which is causing a little to much movement, plus the old prescription is not supporting my foot quite enough. I put some lateral wedging in my shoes under the orthotic, and that helped a little. Also, they are flatter, and don't really contour to my arch as much, and that may be giving them a little more flexibility. I never realized the increased curvature increases the rigidity of the device.

It's difficult, and frustrating trying to find someone who understands a high arched foot. I went on two seperate consultations with two different pods, after I had trouble with the first orthotic, and before I found the second most current pod, and each said, because I walk inverted they wanted to put me in a 10 degree inverted device, and one wanted to include a medial skive, which I know now is ridiculous. I actually let one make a pair for me. Since I'm already laterally unstable I literally almost fell over in them, and they also felt terrible. She didn't seem to care when I told her, and didn't seem like she was interested in fixing them. I hadn't paid for them yet, so I just sent the orthotics back to her office, and never heard from her again, except almost a year later she tried to submit payment for them to the insurance company which was refused. She had received a biomechanics fellowship too. I also now understand what was wrong with the prescription from the first pod, but I don't want to bore you with any more details. Do I have you totally confused yet? Only the most current pod I went to who made my second orthotic (just to rigid) realized I needed lateral support. I may consider going back to him, if I need a slightly firmer device, and ask him to try what you suggested.

Thanks again for listening, and your advice.

Donna

Re: What do u think of leather and cork?

Richard, C.Ped on 2/16/01 at 08:58 (039129)

Hi Nancy,
I am not a fan of leather or cork. We used cork when we first started the business. It was ok, at the time. Through trial and error, I have found that EVA holds up longer than cork. Cork is ok for low impact usage. I just prefer EVA over anything that I have tried. I have treated huge football players over 200 pounds, and their inserts are still holding up very well. The wear them in their everyday shoes as well as football cleats.

I may sound like I am stuck in 'EVA land', but I know the stuff works and holds up very well. I have been send many samples of different materials, and EVA shows the best fit. Cork tends to hold in smells as well. Ewwwww.

I don't like leather either. I can't give you to much of a reason besides it seems 'slick'. I don't like the feel.

I like hard plastic. You can use them as windshield ice scrapers in the winter. You can heat them up and flatten them out to use as table coasters. Great stuff. For an orthosis, nope.

I personally do not believe you can get the best functional orthosis possible by taking a weight bearing impression. Using the Footmaxx or other similar machines will make an ok accomodative orthosis, but I am not a fan of that either.

My personal belief for getting the best cast of your foot is to have a podiatrist who knows what they are doing, use plaster strips in either a semi or non weight bearing position. The second is to use a foam box. Again, the person has to know what they are doing.

Good luck to you. If you have any other questions please feel free to let me know.
Richard

Re: What do u think of leather and cork?

Larry Huppin, DPM on 2/16/01 at 19:32 (039202)

The material is the least important consideration in orthotic therapy. The most important consideration in achieving positive clinical outcomes is the skill of the person who is taking the cast of your foot and writing the prescription.

Given that, every material has advantages and disadvantages. Cork and leather can do the job, but wears out very quickly.

And you are correct, the cast should be non-weightbearing -- as long as the practitioners knows what they are doing. Find yourself a podiatrist with a special interest in orthotic therapy.

Larry Huppin, DPM
Seattle, Washington

Re: What do u think of leather and cork?

Brian G C.Ped on 2/18/01 at 08:21 (039299)

I also prefer eva to other materials, it is easier to mold and spot heat, wears well, and if it is pure eva the device can be washed in antibacterial soap. I have made them for several water skiers and they dont break down or delaminate when wet.

I would say 90% of the 4 to 5 pt I see a week with a bag full of orthotics that are not working are hard plastic. Nothwest Podiatric uses carbon/ graphite with great results, they have it down to a science. It is much more than just a heated and vac formed piece of 1/8 inch material. They lay the fiber up at diff angles to control flex region of device. I use them with great success for skaters and dress orthotics.

I think many practitioners are taught that the device has to be very hard to control foot function, While this may be true for the hypermobile foot, you still can get a great funtional device with eva.

The problem i see most often is the pt that over pronates gets a device that is 3/4 length(not always bad) that has no forefoot correction, and the rearfoot is either neutral or has a weak post. many try to rely on the arch to 'correct' the foot. Many over pronators have tight heel cord. Lack of rearfoot control and some lift causes the midfoot to collapse into the arch of the device at mid stance on.

That in my opinion is one of the reasons I hear 5 times a week 'I tried to wear it for a few weeks and it felt like a golfball under my arch, so i stopped wearing them'

Re: How to find good orthotics

Larry Huppin, DPM on 2/18/01 at 11:08 (039305)

A patient should not be looking for a specific material, but rather for a good practitioner. If correctly prescribed and manufactured orthoses will be comfortable regardless of durometer (hardness) of the material. In fact, a quality practitioner should guarantee orthotic comfort. They will not be able to guarentee complete resolution of symptoms as orthoses are only a part of a total treatment plan, but you should always expect comfort. Ask the practitioner if they guarentee the devices will be comfortable. If not, find another practitioner.

I can never understand why people will simply accept an uncomfortable orthosis and throw it in a drawer, when if they had a pair of eyeglasses that were causing headaches they would head direclty back to the optometrist.

The Northwest Labs graphite is a great material and I use it often for ski boots, dress shoes, etc. But polypropylene is also a great material and somewhat easier to work with. The material is of only minor importance. Orthotic comfort depends on:
1. The cast of the foot
2. A prescription that truly addresses the patient's foot biomechanics and structure
3. The positive cast made by the laboratory
4. The relationship between the shoe and the orthosis

The work that the lab does on the positive cast is critical. For accurate positive cast work consider practitioners that use one of these three labs to manufacture their orthoses:
Northwest (www.nwpodiatric.com)
ProLab Orthotics / USA (www.prolaborthotics.com
Precision Intricast (www.dpmlab.com)

ProLab sends out a weekly e-mail newsletter with extremely helpful hints on improving orthotic therapy. Some people may be interested in signing up for those.

Larry Huppin, DPM
Seattle, Washington

Re: Reply to Dr Huppin How to find good orthotics

Donna SL on 2/18/01 at 20:08 (039351)

Dr. Huppin,

I don't agree that the type of the material used in an orthotic is not an important consideration. I think many people need an orthotic shell with some give to it. You must also consider the foot type. People with cavus feet like myself, or someone with arthritis, or even a flat foot, etc., may not be able to tolerate a semi rigid material for whatever reason, no matter how well the orthotic is made. There are so many wonderful materials out there, that can be combined to make a comfortable, strong, supportive, and controlling orthotic. This type of device of course takes more time, and more skill to make, and requires some creative thought to produce. I think the polypro orthotics that are being offered by most pods are a cheap fast way to produce orthotics. I don't think a 'one type of material fits all' approach can1 be taken. The reason people are seeking the services of Cpeds, orthotist, etc. are because they are willing to keep up to date on state on the art materials, and material synergy for orthoses, and are striving to produce functional comfortable orthoses. I think Pods should be able to give the patient something more comfortable, and offer more options for what they are charging. If you do a search on orthotics on this board you will see many orthotic failures from devices made of rigid to semi rigid material. I'm sure there are many failed orthotics produced from some of the major labs you have mentioned. Can they all be blamed on poor casting, or corrections?

You may be interested this article.

http://www.biomech.com/db_area/archives/1997/9703materials.bio.html

I had several pairs of orthotics made out of the semi rigid polypropylene. The first pair precribed by the first pod were extremely uncomfortable, but I kept trying to break them in. They were also made at one of the big labs you listed. It was one of the worse orthotics I ever had. After many adjustments they still caused much pain, and eventually injuries that I am still recovering from.

I got a second opinion from another pod, who said the first ones hurt, and caused all my injuries, not because of the material, but because they were the wrong prescription for my foot type, and said polypro, should be comfortable with the proper prescription, and offered to make me a new pair. He was also concerned that there may be some permanent damage from the first pair.

As a matter of fact, the first and second pod mentioned above are probably among the finest biomechanic experts in their field (names I know you would recognize). They both took a perfect cast. I had extreme confidence in the second pod who meticulously corrected the cast himself, and then made the orthotic device personally. The new orthotic prescription felt more correct, and helped relieve some of my symptoms, but the material still hurt, and was too hard and rigid, and I could not wear them more than around 20 minutes at the most, without causing pain even after many adjustments. They are sitting in a drawer . I asked if he could make something a little softer, and he went to the other extreme, and made a functional orthotic out of pink and white plaztozote, that were much more tolerable, but a little to soft and bulky, and had horrible durability. They initially helped stabilize my foot comfortably to allow some healing. When they started to break down (which was very quickly) they started causing other problems . I asked if he could make something in between with more durability (EVA, or a multidensity orthoses, etc.), but he wasn't really interested, and said 'those materials are a Cped thing'. I still think he is an excellent pod in the area of biomechanics, but ignorant in many of the other materials available to produce orthoses.

Neither pod guaranteed their orthotics. Most in fact ask for payment up front, and offer no guarantees.. Since the money was already invested, I kept trying to get them to work. I invested a large amount of money, and time, and still do not have a new orthotic to show for it. I have talked with many people who have different foot types than I who experienced similar problems.

Years ago I had an orthotic made a from a very flexible thin polypro supported by a poron arch fill from another lab. I was told later this lab does not do a great cast correction. At the time, it was the most comfortable orthotic I had ever had, and I thought they were a successful orthotic with only some minor problems, that I thought could be corrected. I went to the first new pod listed above, because they needed some refurbishing, and wanted to have a second pair, and the original pod who made these was no longer available. This new pod told me my current
orthotic was no good, and preceded to make the ones that caused injury.

The reason I sought orthotics in the first place was because I have a high arch, and had only some metatarsal discomfort. The semi flexible ones seemed to be the most comfortable, and provided much relief, and never caused any injuries. After wearing the more rigid polypro ones, over a course of a year, I developed a bad case of PF, and severe tendonitis in the heel, most of the foot, and lower extremities.

Just recently out of frustration I picked up my perfectly corrected cast from the second pod, and took them to a orthotist/cped who owns
a small private lab. He is going to make an orthotic out of several different materials. He claims this combination will give both comfort, and durability. It is going to made out of pro xp2, ucolite, trilam, and reinforced with thermal knit, and maybe one other material I can't remember. These are much more expensive materials, and a much more labor intensive orthotics to make, yet he is charging me less than half of what the other orthotics cost. He took a cast himself, and offered to correct it, but I requested that he use my most recent cast from the second pod. He also has a cad/cam system for producing EVA orthotics which he uses on many patients with success, but felt with my foot type I would benefit most from the orthotics created from the traditional non weight bearing plaster cast method with the above listed materials. .

I haven't received them yet. If these don't work with a more forgiving material, I will assume that my foot cannot take a full correction, but will stick with a more accommodative material. If the cast can't be adjusted I would probably seek a new DPM who would take a new cast if necessary, but who would be willing to work with this orthotist/cped.

From the majority of the orthotics I see being produced profit seems to be more important than patient comfort. Most of these large labs offer very
few accommodating materials, and keep producing single density orthotics, other than for the top cover. I feel this is because they are easy, and
inexpensive to produce. They may offer a few of the softer thermoplastics for diabetics for example, but either the dpm's or the labs are not fully utilizing the selection of materials that are out there, in the proper combinations. The semi rigid orthoses may work for some people, but I think in other cases podiatrist should be willing to work as a team with cpeds, orthotist, and the patient in improving orthotic comfort.

I'm still not the same as I was before got injured from the first orthotics, but am around 70% to 80% better most of the time. I can tolerate the original semi flexible ones for a couple of hours now with some additional wedging, but still cannot wear the semi rigid perfectly corrected poly pro ones made from the second pod above, nor do think I ever will be able to.

Lastly , I sometimes think orthotics are prescribed too quickly, when someone comes in with a foot problem, or injury, and they may not be the first line of therapy that should be offered. When I first got injured from the first pair of orthotics, the second pod immediately made a second pair which helped resolve a very small portion of my symptoms. Only after months of trying orthotic therapy, did he finally recommend physical therapy. Only then did my symptoms start to improve dramatically.

Donna

Re: How to find good orthotics

Richard, C.Ped on 2/19/01 at 08:20 (039380)

Good morning Dr. Huppin,
I know that with me, EVA is the most comfortable that I have ever worn. I have experimented with many material on myself so I will know pretty much what the patient is feeling.

About people throwing their orthosis in the drawer. I agree with your example of eyeglasses. Customer service should be top priority. To many people are in it just for the money. I hate that. I really do. I don't know if you have ever read the past posts that some people have written, but for some, it is very difficult for some to get the proper adjustments needed. People have complained that the doc or professional told them that they would get used to it. Some people have told me that their professional allows two adjustments, then they will start charging for them. Some charge right off the bat. I don't do that. If it is not right the first time, I will fix it.

I know that the hard plastic inserts that do not have posting is very difficult to adjust. I have had DPMs write and Rx for me to add posting just so I can interface the orthosis with the shoe. I do question the education and experience of some people that fabricate these things. The work that I have seen can be described as no less that a joke.

I don't do that. If it is not right the first time, I will fix it.

Have a great day,
Richard, C.Ped

Re: Reply to Dr Huppin How to find good orthotics

Larry Huppin, DPM on 2/19/01 at 20:35 (039422)

Donna,

I'm sorry you have had trouble finding comfortable orthoses, but I think you misunderstood my comments. I agree that material is an important consideration when writing orthotic prescriptions - personally I regularly use over 10 different major materials for orthotic fabrication. But material choice is only one portion of an orthotic prescription and not the most important. Casting technique, correction, size, contact, control techniques, shoe recommendations, the amount of deformation during weightbearing, topcover materials, etc., etc. (this list could go on for a couple pages) are all as, or more, important. Given that, every material and combination of materials has inherent advantages and disadvantages. The most important consideration is the knowledge and skill of the practitioner. That's why one of the first questions that should be asked of any practitioners is 'do you guarentee comfort?' No practitioners, regardless of the letters after their name, can guarentee a specific clinical outcome. Orthoses are usually only part of a treatment plan. But if the practitioner is confident and experienced in orthotic therapy, they should guarentee that you will be comfortable in your devices. If you are not, they should be willing to make adjustments, replace them, or refund your money. In my office if we have to make more than 3 adjustments for comfort on any pair of orthoses we reevaluate the situation and start over again. At any point, at the patient's discretion, they may receive a complete refund. I think it is fair for you to ask the same of anyone who is making orthoses for you. If they are excellent practitioners of orthotic therapy they will rarely have to make that refund.

I am very familiar with the article you mentioned. It makes some points I agree with and some that I don't. Keep in mind that it was written by the president of a company that sells the materials mentioned in the article.

There is good, bad, and average in every medical specialty and orthotic therapy is no exception. I hope that this next pair works out for you.

Good luck,

Larry Huppin, DPM
Seattle, Washington

Re: Thanks Dr. Huppin

Donna SL on 2/22/01 at 04:02 (039620)

Dr Huppin,

Thank you for your response the other day. You seem like a very kind and
thorough practitioner, and offer a rare guarantee. It seems reasonable
that after 3 adjustments if the orthotics are uncomfortable, or in my
case caused extreme pain then there is something very wrong with
either the prescription, material or both, and the situation should be
re-evaluated. I now realize , even the most experienced practitioner
can make a gross mistake, and just not understand your foot type.
Unfortunately it is usually at the patient's expense, both physically,
and financially. Office visits and adjustments are charged in addition
to the cost of the orthotics.

Prolab seems to be the lab most used in my area. Does Prolab have
different densities of polypro? It seems like the polypro they used on
a pair that I had made from them a while back was very hard, even at the thinner density. The shell color was clear, or what they call natural. The orthotics I had made at KLM years ago were made from a 3mm polypro, but it seems like a slightly softer plastic. When I push in on it, it has some give to it. Do you know if KLM uses a different type, or are there different durometers of polypro? Also, does Prolab have more materials available then are listed on their web site? (i.e. different densities of EVA, other top covers, etc.) I also inquired about Northwest labs technology once, and a pod said they are difficult to adjust with spot heating.

May I ask what materials, and/or orthotic design you've been successful with for someone like me who has high arches, supinates excessively, causing lateral instability, but has some midstance pronation in one foot, (may be due to mild Planterflexed first ray) and is still somewhat sensitive in the heels, and arch? Have you had any functional orthotics fabricated out of EVA?

Donna

Re: Thanks Dr. Huppin

Larry Huppin, DPM on 2/22/01 at 12:54 (039651)

Donna,

ProLab can make any rigidty of polyproylene - from super flexible to hard as a rock. All the lab does is to fill the prescription of the practitioner who writes the prescription. The practitioner should be aware of what factors affect rigidity - for example, take an orthosis made of 5/32 inch polypropylene. For someone with a very flat arch, this would be an extremely flexible device. For someone with a high arch it would be quite rigid (all materials become more rigid with greater curvature). ProLab does use a very high grade of polypropylene so that the devices last longer - it may be more rigid for the same thickness as poly from other labs. That just allows you to use a thinner poly for the same strength. But even for someone under 100 pounds,, if prescribed correctly you can get a very, very flexible poly device if you wish.

I'm hesitant to answer what material I might use for your foot because there are just so many different factors involved. But, and take this with a grain of salt, here might be a suggestion as a starting point for a high arch:

1/8' poly shell. Left as is, this would be extremely flexible. Actually too flexible ot provide much control. So, we would add an EVA arch fill. This will provide some shock absorbtion and make the device more supportive. But it also gives us the ability to make the device more flexible simply by grinding out some of the EVA. A soft topcover to the toes or sulcus (depending on shoes) for comfort. A wide device is imperative to ensure comfort and control. Also an extension under met heads 4 and 5 extending back under the met shafts will help control the lateral instability. Keep in mind that is not by any means a complete prescription - but hopefully it gives you some idea of the way I might start.

I have done a number of functional orthoses out of EVA and they work fine. My only problem is that if they are pure EVA (with no shell at all) they do not last very long. Like EVA in a running shoe, they will lose much of their resiliency in about 400 miles. As long as the patient is aware of this, they are fine devices.

ProLab has almost every orthotic material available. Many densisties of Plastizotes and EVAs, Poron, Corks, 10 or so topcover materials, etc. They will do whatever the doctor prescribes.

And you heard correctly - NW graphite, while the thinnest material available, is very hard to adjust. As I said, there is no perfect material Each has advantages and disadvantages.

Larry Huppin, DPM
Seattle, Washington

Re: Thanks again Dr. Huppin

Donna SL on 2/22/01 at 19:00 (039679)

Dr. Huppin,

Thanks for your advise. I looked at my old medical records, and a copy of the Prolab order form, and the shell was 5/32 inch poly, with no arch fill. The pair made from the second pod look even thicker, so that's why they must have seemed so rigid to me (I'm only a medium weight). None of the orthotics had any forefoot wedge type extensions.

The Pro-aerobic orthotic from Prolab seems close to your description. I asked the Pod who made the above orthotics once about the Pro-aerobic, and he said they would be more rigid, but I don't think that's the case now. I also just noticed Prolab has a device called Featherweight with a suborthalon shell.

In case the softer material on the current pair I'm waiting for don't seem supportive enough, or breaks down to fast, I would ask whom ever I go to if they would give what you described a try. I'm starting to be able to tolerate my old KlM poly orthotics which have a similiar design. The only difference is there is a poron (enduro) arch fill, which is causing a little to much movement, plus the old prescription is not supporting my foot quite enough. I put some lateral wedging in my shoes under the orthotic, and that helped a little. Also, they are flatter, and don't really contour to my arch as much, and that may be giving them a little more flexibility. I never realized the increased curvature increases the rigidity of the device.

It's difficult, and frustrating trying to find someone who understands a high arched foot. I went on two seperate consultations with two different pods, after I had trouble with the first orthotic, and before I found the second most current pod, and each said, because I walk inverted they wanted to put me in a 10 degree inverted device, and one wanted to include a medial skive, which I know now is ridiculous. I actually let one make a pair for me. Since I'm already laterally unstable I literally almost fell over in them, and they also felt terrible. She didn't seem to care when I told her, and didn't seem like she was interested in fixing them. I hadn't paid for them yet, so I just sent the orthotics back to her office, and never heard from her again, except almost a year later she tried to submit payment for them to the insurance company which was refused. She had received a biomechanics fellowship too. I also now understand what was wrong with the prescription from the first pod, but I don't want to bore you with any more details. Do I have you totally confused yet? Only the most current pod I went to who made my second orthotic (just to rigid) realized I needed lateral support. I may consider going back to him, if I need a slightly firmer device, and ask him to try what you suggested.

Thanks again for listening, and your advice.

Donna