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To BG - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

Posted by Donna SL on 8/19/01 at 20:20 (057203)

BG,

Have you ever heard of a casting method called the three point system, or three point pressure system (can't remember exact name). I decided to talk to a certified orthotist/prosthetist to see how he was producing orthotics, and get a second opinion. He said the method by which he cast the foot is by putting it in a foam box, and the lining up the three points of the foot. Is this just bascially an accomadative cast?

Initially I had orthotics made off a non wt bearing cast that had very similar parameters listed in your article on cavus feet, except the arch was perfectly contoured to my foot. The cast is balanced to neutral. Since the orthotics were still not working I showed my pod your article months ago, so he would reduce the arch height. Instead of redoing the cast by adding more arch fill to the positive cast to reduce the arch height he decided to make a new orthotic using an eva material pressed off the original cast, and ground out an excessive amount of material in the arch area of the orthotic, so it would flatten. This doesn't seem to be working, because a lot of the support seems to be lost this way. Is not altering the cast directly a poor way to reduce the orthotic arch height?

The orthotist said my orthotics are not working because they weren't made off a semi-wt bearing cast, and he's had much more success with his method. I am reluctant to try him, because he said there are no gurantees.

Does a semi wt bearing cast really produce better results for a high arched foot than a non wt bearing cast, or would altering my oringinal cast work just as well? I know you use a cad/cam method, but I assume the principals are the same.

Donna

Re: To BG - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

bg cped on 8/19/01 at 21:51 (057211)

That depends on what he is doing. If it is standard bio-foam squish box. That is similar to that soft styrene type foam they use in flower pots. You can get good results with that method but it is dependent on the skill of the one taking cast.

If you have a rigid cavus foot sometimes semi wt bearing is good method in foam. You can grind under arch to make it less firm. you can fill the arch in the cast. did they post the fo on the lateral border? how did your foot respond when/if that was done? what is your main symptomand did certain things work better or worse?

I know it is confusing, it is also hard to explain how to make it correctly. I can do them in my sleep when I have the person there but there is no set way to describe it to someone else.

Re: To BG - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

Donna SL on 8/20/01 at 03:48 (057230)

Hi BG,

Thanks for responding so quickly.

The orthotic my pod recently made did have a reinforced lateral border. He used birkocork to reinforce the lateral side, and it worked very well in
controlling my supination. Without it the eva shell wasn't strong enough to control the supination. But, without strong midfoot support normally
provided by a higher arch I starting rolling onto my big toe joint, and had more pressure on the forefoot in general. Also the softer arch support causes the fascia to feel stressed and strained, yet I can't take anything pressing on my arches. To even out my metatarsals, and to take care of the plantar flexed first ray my pod has intrinsic valgus posting in the orthotic, which seems not work if the material is too soft. He was thinking of reinforcing the forefoot areas with a liquid thermoknit, but I think he would be patching it up all over the place with this stuff.

The one problem with the cavus foot theory for me anyway is that if you post the lateral side of the foot, it is now going to cause the foot to pronate in the mid or fore foot stance. How do you keep from driving the first ray into the ground if there is a plantar flexed ray involved, which makes the arch sort of feel like it's collapsing if the arch on the orthotic is to low, or too soft, because now the medial side is not balanced off the lateral side? Also, if too soft of a material is used it seems unable to take pressure off the met heads. Just putting a recess under the first met doesn't seem to work, and just causes the first ray to be driven further into the ground, because it causes more forefoot pronation.

How can a functional orthotic work if most of the shell is too soft, or the arch is too low? What's left to control the foot? Also an ankle equinus which I have even complicates things more. It really seems like a traditional orthotic shell made out of a singe density material can't really work for a cavus foot, unless maybe it's reinforced in various areas. Most traditional neutral balanced Rooterian orthotics seem to work by off loading the weight onto the arch, and/ or depend on deep heel cups for control - which neither can really be tolerated in most cases by a cavus foot with an ankle equinus. It seems like a different design is needed.

I was just wondering what the magic of a semi-wt bearing cast could provide that this orthotist is talking about. Unless the orthotist isn't using a traditional orthotic design. Tonight I found an article in the O and P library that describes a non traditional orthotic for hyper pronated feet, and I'm wondering if the orthosis he would be using is based off the same theory , but with with cavus foot modifications. He said he would use soft materials. The article mentions something about the 3 point system. Maybe you could comprehend it better than me.

http://www.oandp.org/jpo/library/1997_02_077.asp

I could ask my pod to get a foam casting box. He's really open to anything if you felt the semi wt bearing method is more advantageous. I don't peronally see how much could be changed with the foot in a semi wt-bearing position. If this 3 point system method isn't some fancy method, and it's just a matter of getting the foot in neutral while in the box, I'm sure my pod could cast me this way, but am wondering if it would solve any problems, without changing the traditional orthotic design itself like adding a medial border to stop the foot from rolling in to compensate for the lower arch height, reinforcing other bits of the orthotic, etc.

Donna

Re: To BG - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

Ed Davis, DPM on 8/20/01 at 14:49 (057293)

One of the weight bearing or semi-weight bearing methods is more likely to work for a cavus foot than for a 'flat' foot.

You are correct about a 'general' lateral wedge or post inducing additonal pronation or arch strain. I have not examined your foot but, by description (if I can do some guessing) you are suggesting that you have a cavus foot with a rigid forefoot valgus foot type (generally includes a plantar flexed first metatarsal) coupled with some compensatory subtalar joint pronation.

Use of a semi-rigid orthotic (emphasis on 'semi') casted non-weight bearing, possibly with a plantar fascial groove in the device, the device molded 'tight to cast' (minimal plaster fill on the positive cast) but with the subtalar joint in mild pronation may be the way to go. Only the FOREFOOT is posted in valgus---as such, no subtalar joint pronation is induced but there is pronation of the midtarsal joint around its longitudinal axis (supination of the midtaral joint around its longitudinal axis is the proximate cause of plantar fasciitis while subtalar joint pronation is often the underlying culprit that induces such motion). The feeling of the first metatarsal being 'driven into the ground' will not occur since the forefoot valgus post allows a GRADUAL distribution of forefoot pressure away from the first MTP joint.
Ed

Re: To Dr. Davis - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

Donna SL on 8/20/01 at 17:28 (057320)

Hi Dr Davis

I had a orthotic that induced slight pronation, and I think the design was similar to what you were describing with valgus posting, and the effects were devastating , and I'm still recovering from them. That design twisted my foot like a pretzel, and caused severe pain, and inury. I'll show my pod your post next time I see him in case I'm wrong, although I doubt it. He's familiar with all my old orthotics.

My current pod says I'm an excessive supinator, and very laterally unstable, and my foot needs varus wedging. I'm looking at some old notes he wrote, and it says my foot needs major support through the calcaneal cuboid, and the cuboid fifth metatarsal area to help stabilize the foot. He also mentions that I have a plantar flexed first ray of 0 -2 degrees. He did a coleman block test, and said it's not fixed. The right foot supinates much more than the left. Also, he says I only have a slight forefoot valgus. He said the only reason it appears that I'm pronating is due to the foot being unstable laterally, and that I have contact phase supination that then leads to late mid-stance pronation. The less I roll out then the less I'll roll back in. He told me I do not have any abnormal pronation at the calcaneous area/ subtalar joint at all. The slightest bit of anti-pronation control only makes this worse. My foot is like the one described in the cavus foot article in the biomechanics magazine. My pod invented a special inverted device for severe pronators, so I feel confident he knows I can't take any type of anti-pronation control, because he's seen and treated so many feet opposite of mine. He said none of my prior orthotics had any lateral support.

He originally tried the lateral design approach with semi rigid plastic. I couldn't tolerate it, because the plastic seemed too hard on the arch, and heel even with a spenco/poron top cover. He put a plantar fascia grove in that didn't help either. He says he used a slight fill in the arch, but it doesn't appear so to me. The device killed my arch, fascia, and heels. He also has intrinsic valgus posting in his design. I think the pain I felt throughout the foot especially the heels was due more to the stress on the foot, and irritation of the nerves from struggling to get over the high arch than the plastic, because I've tolerated plastic before in a non controlling orthotic with a flatter arch. The same design made out of EVA felt even worse, I only have around 5 degrees of ankle dorsiflextion, and the high arch seems to make it more difficult for me to walk. It puts stress everywhere. I don't think he was aware of the ankle equinus when he first started with me, but is now. I can't tolerate a deep heel cup either because it presses on my nerves that are still recovering from entrapment of both the lateral plantar nerves, and the first branch, that runs right along the medial
side of the heel.

The design only became somewhat tolerable when he lowered the arch, and used a softer material. Also, when he reduced the arch he was able to reduce the lateral support, because the medial arch didn't push me out as much. I do prefer a flexible plastic because it feels more stable, but could only tolerate in on the heels if there was a very soft pad, which might jeopardize the stability in the heel. Also it couldn't press on the arch area either.

Should I give up? Only kidding. I'm curious though why you feel a semi-wt bearing cast would be more beneficial for a cavus foot. The orthotist I just saw is so busy that it takes 2 to 3 weeks to get an appointment each time, so I really prefer to stick with my pod. I'm just thinking it might be worth the wait, because maybe the orthotist are approaching this whole problem at a different angle, and the orthotic design they are using is unique, and there is more to it than just using a semi-wt bearing cast.

Hope I didn't confuse you with this long post. I appreciate any continuing thoughts you may have on this.

Donna

Re: To Dr. Davis - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

Ed Davis, DPM on 8/20/01 at 20:32 (057351)

I am unsure about a number of things you mentioned in the second paragraph.
If you are an excessive supinator, why do you need varus wedging? What is the reason attributed to the late midstance pronation (assuming you are refering to subtalar joint pronation)? Excessive late midstance pronation?

You are correct about the lack of ankle dorsiflexion being a problem. Individuals with high arches need even more dorsiflexion than those with low arches. You may find only fair orthotic tolerance until you stretch out your gastrosoleus achilles complex, despite the manner in which the orthotic is made.

Feet which are rigid or semi-rigid cavus foot types deform less on weight bearing and that is the reason why weight bearing or semi-weight bearing techniques offer a more better 'capture' of that foot type than say, a flexible flatfoot which looks very different weight bearing than not. Despite that, I still prefer the non-weight bearing prone casting technique.

At this point, I would really need to examine your feet before I could accurately sort out the information provided. I have to admit that you have really piqued my curiosity as the info. is not totally 'adding up.' If you come to the Seattle area, I would be willing to make you an orthotic which you would only pay for if it definitely worked-- you would make the decision if it is successful or not.
Ed

Re: To Dr. Davis - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

BG CPed on 8/20/01 at 21:03 (057358)

I also noticed the 'varus' notation. What I have seen and what Dr Davis is talking about (I think) is tight gastroc/limited dorsiflexion will cause or try to cause your foot to pronate. This is because you are not getting the motion from your ankle. Many folks with tight gas will turn feet out a little, this allows the the body to pass over the foot without the ankle dorsiflexing much. If you are tight and try to walk with your toes pointing straight ahead, most likely your heel will bounce or lift premature.

If you have a plantarflexed 1st and a forefoot valgus. you cant push your 1st thru the floor so it want your forefoot to supinate and the rearfoot want to pronate, As Dr Manoli says it is like twisting a wash rag. You have a type of push me pull me going on in your foot. If the arch is too high or hard, and depending on how the forefoot and or rearfoot is posted you cancause the arch to be uncomfortable. Many folks dont give enough consideration to the relation of forefoot to rearfoot mechanics, one will influence the other. Many just make a hard device with a very high arch and a little dab of post under heel. I works for some but is not good for true cavus foot.

I see several per week that have cavus and are told they pronate. I think this is due to tight gastroc and equinus that present in this foot. They may have some mid to late stance pronation, but the foot is still cavus, they see it collapse some an say 'yep thats pronating' what they are seeing is the rearfoot/gastroc overcoming the forefoot structure, like the twisted wash rag.

Another common mistake I see is a cavus foot with a lateral wedge under the heel, this can cause many problems and is not indicated in the majority of cases. Donna has any of your Doctors done a Coleman Block test on you? it is VERY simple and is an easy way to see if you would be helped by a cavus device. Also if you have peek-a-boo heels, this is another indicator.

Dr Davis I see you are near Seattle, You must know Dr Smith at Northwest Pod . I know Lisa and a few others from there. They are the only Lab I use when I dont make them myself.

Re: To Dr. Davis - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

BG CPed on 8/20/01 at 21:14 (057359)

Donna my bad, I did see that he did a Coleman on you. The question I left out (phone rang)was if you look at the Coleman test. It corrects the foot with no arch at all, it is a piece of wood. You indicated that he reduced the medial arch, and reduced valgus post at same time, did he try to leave the valgus alone first?

Dont want to confuse you and I dont want to make your Dr strangle you. Just a thought...now you can see why we wrote that paper, there are more of you around than most practitioners think. I had 2 more today that were treated same way, fixed both up very well

Re: To Dr. Davis - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

Ed Davis, DPM on 8/20/01 at 21:54 (057367)

Yes, I am familiar with Dr. Smith and use his lab.
Donna claims a low degree of forefoot valgus but I really have to wonder about that measurement. Forefoot supinatus, that is a forefoot position distorted by excess supination at the longitudinal axis of the midtarsal joint, falsely increases the amount of forefoot varus measured or decreases the amount of forefoot valgus measured. I have to wonder if that is what is going on with Donna. I attempt to 'cancel out' any forefoot supinatus when casting for orthotics by manually pressing down on the first metatarsal head--- Paul Scherer, DPM of Prolab (San Francisco) teaches this and has a lot of good educational material on this subject.

It is really the midtarsal joint longitudinal axis supination in late midstance that strains the plantar fascia, particularly notable in individuals with equinus---bringing the first ray down while taking the orthotic cast really helps in such cases.
Ed

Re: To Dr. Davis - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

Ed Davis, DPM on 8/20/01 at 22:00 (057368)

PS Agree with you about the lateral wedge under the heel--avoid, avoid.
Another thing to look for in Donna is calcaneal varus and my guess-limited STJ eversion ROM available. Somewhat tough to control--would use deep heel cup with only a few degrees of varus in heel post. This may not be a big issue though because she spends little time on heel with her equinus.
Ed

Re: To Dr. Davis - i meant valgus posting

Donna SL on 8/21/01 at 04:34 (057397)

Dr Davis,

Opps my error. I guess I meant a valgus wedge to control the varus. It's along the the lateral side of the orthotic.

As far as the late stance pronation, that's what I was trying to explain in my previous post, about rolling out, then rolling in. Try to imagine the foot like a see saw moving laterally to medially. The arch doesn't really collapse. It seems to stay rigid. The whole foot will start to tilt in at late stance after excessive contact supination. The forefoot pronation seems to only bother me in my right foot, because that one supinates more. My left foot seems to be taking more stress though. I can feel how supinated I am, and my peroneals get so irritated if I don't at least have some type of lateral wedge in a shoe, and this also has affected my back. I wish I could show you what I mean.

There is also some discussion in the podiatry uk mail board about supination
http://www.mailbase.ac.uk/lists-p-t/podiatry/
A bunch of pods from all over the world have all kinds of podiatry discussions, mostly about biomechanics. In an older thread called Supination Therapy they talk about this foot type, and they give various reasons why this foot type exist, and suggest treatment They make their treatments sound so easy to implement.

I've been stretching like crazy, and I think I was even worse than this before. My chiropractor has helped me gain a few degrees of dorsiflexion
through ART, and ankle manipulations. I recently read an article in JAPMA written by a DPM named Howard Dananberg, who claims he can dramatically increase dorsiflexion. Are you familiar with his methods, and know if they really work? I know an equinus can make orthotic therapy difficult. Even if I wear an athletic shoe, I need to add a small heel lift, or it feels like I'm walking out of quicksand in my rear foot. The heel lift of
course puts more pressure on the forefoot. All the orthotics make me feel even worse even with a little heel lift. I can't seem to stand a negative heel feeling, which seems to occur in any functional orthotic. They all start to trigger the heel, and arch pain again. It appears that with an ankle equinus more weight is put on the heels.

In reference to your following post on casting my pod had been a highly respected professor in biomechanics for many years at CCPM, and also
has been in practice for almost 24 years. I feel confident he takes a perfect neutral cast, and knows what he's doing in that respect, and removed all supinatus from the cast. I live in San Francisco, and have had some other biggies from CCPM take good cast, and also had some cast taken that were horrendous.

I also spoke to Dr. Schere a couple of months ago. I had called him, because he had written an article in Podiatry Today, and he seemed to
understand my type of foot, but he said he couldn't see me, because he's retired from private practice. He said he doesn't understand why so many
pods don't know how to recognize, and treat this foot type.

As far as the valgus measurement my current pod extensively checked, and rechecked all my measurements. He said he could not believe the other
pod's measurements had an 8 degree forefoot valgus, that he insist is absolutely incorrect, and the valgus is very slight.

I've improved so much since I haven't been wearing any of their functional orthotics, yet I'm still not really comfortable, because I still don't have an orthotic that is even somewhat accommodative. In the interim I've been wearing otc spenco orthotics with tape for stability, and heel lifts with some lateral wedging in the shoe which isn't great, but is better than nothing. I'm just at the point where I can't stand taping anymore, and my metatarsals seem to be getting worse wearing the spencos, even though my heel and arch pain has improved greatly. I still need to stay on meds though. Also, even with insurance it's cost me a fortune in both time and money, and I have no orthotic to show for it.

If I ever come up to Seattle I'm going to take you up on your offer. You may have more of a challenge than you think, or maybe you'll solve all my
problems. I had read that Northwest labs can vary the flexibility in various parts of the orthotic which is what I think I need, but again it doesn't seem like they can be adjusted. I can't even ask my pod about the semi wt bearing casting right now, because he will be out of town for 3 weeks. I don't know if I will get much more accomplished with him at this point anyway. I'm getting tired of giving him cavus foot lessons. Also, I can't get an appointment with the orthotist until mid September. I can't believe this is such a hard problem to solve. It seems to me someone is missing something.

Dr. Davis, I can't thank you enough for the input you have given me so far, and that wonderful offer.

Donna

Re: To BG cped Dr Davis - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

Donna SL on 8/21/01 at 05:43 (057400)

Hi BG,

I had posted to Dr. Davis earlier that I made an error, and meant a valgus post, not a varus post.

I'm confused about your Coleman block question. If you mean if I stand on the block, and the varus corrects then that is true. But what do you mean by no arch at all? My arch stays up, and I've had the test with nothing under the arch. Do you mean having the test with something under the arch?

As far as the lateral post. At first my pod had a high medial arch, and a high lateral post. I was still supinating over the lateral post when he used a softer material, and my foot just abducted all over the place with a semi-rigid plastic. He also had a very deep heel cup which also exerts an anti-pronation force.

I then asked him to lower the arch, because I referenced your article that said a high arch doesn't let the foot pronate. I noticed the high arch keeps the foot from pronating at the heel which is the area I need to pronate at. When he lowered the arch, he knew he had to lower the lateral side so I would be in balance. The lower arch, lower medial post combo was much more effective in controlling the supination then the high arch, big lateral post combination, because I wasn't fighting the high arch. The control worked better in both plastic, and EVA. He had tried lowering only the medial side in the past leaving the lateral side as is, and it caused pain on my first met.

I'm just wondering if he had redone the cast with maximum arch fill to lower the arch rather than grind it out of the orthotic itself to flatten the arch I would have a more supportive orthotic, and not have all these problems. He made it so thin that there is no support left in the midfoot, or forefoot. The forefoot valgus correction can't work, because the orthotic shell was only made out of a 30 durometer EVA to begin with, and the forefoot needed to be thinned when he thinned the arch out.

This weekend I did some additional research, and I have read over, and over again that there should be extra medial expansion in the positive cast, by pods who were familiar with treating cavus, laterally unstable feet. I've mentioned this to my pod many times before, yet he has yet to change the cast itself. I have the cast at home, and am debating if I should just take the cast to another orthotist technician I know who has a lab, and let him fill the medial arch, and repress a new pair of orthotics over them. He said he could duplicate the cast and work on the duplicate. My pod has been so reluctant to do this in the past, because he seemed worried about how much to reduce the arch, and was just playing around with the orthotic instead.

At this point it's hard to know if I'm getting arch strain from the orthotic shell being so unsupportive, or from too much lateral correction. The only part that is left that is strong is the lateral side that's been reinforced with birkocork. There's not much left of the rest of the shell.

I agree there are a lot more of us around then most pods seem to realize. I see tons of people walking on the outside of their feet.

Donna

Re: To Dr. Davis - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

Dr. Zuckerman on 8/21/01 at 11:10 (057423)

Hi,

I have found that there even if you completely evaluate the need for orthosis with a gait analysis and biomechanical evaluation there are just some feet that can't tolerate the orthosis. Having a pes cavus with ankle equinus is one of them. You may need to take a look at lengthening the achilles tendon to remove the equinus. In addition the ankle joint needs to be evaluated for any boney restrictins.

You have a very tough foot structure that is very very difficult to treat with orthosis

Re: To Dr. Davis - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

Donna SL on 8/21/01 at 13:38 (057442)

Dr Zuckerman,

I agree some people can't tolerate orthotics with both high, and low arches. I just wonder sometimes, if it was because they weren't prescribed the proper orthosis. I tolerated orthosis for over five years before I was put in the wrong one. The one I had prior was sort of between an acommodative and functional orthotic, and it never caused any injuries, and provided a tolerable amount of comfort.

The closer the I've had my pod get back to that type of correction the more tolerable the orthosis becomes. I've just had such a hard time in the past convincing these Rooterian purist that not everyone can tolerate being corrected to neutral, and just try to accommodate the uncomfortable spots in the foot, and use maybe half the correction, even if it seems a little unconventional. I may be better off finding someone that has worked with diabetics, and geriatrics, who is more familiar with accommodating the foot, instead of trying to correct it so perfectly. I think that was the attitude of the orthotist I met last week, but need to speak with him more.

The more I heal, the more I can get around mostly taping, and using OTC spencos, and lateral wedges, with mainly just forefoot discomfort. This convinces me that I could benefit from some type of an accommodative orthotic.

Thanks for the suggestion, but there is no way in he world I would consider any type of surgery for lengthening the achilles tendon after what I've read on this board. As far as bony blocks would that have shown on a MRI, or x-ray which I've had? They all appeared normal. How else is this evaluated? My chiropractor didn't think I had any bony restrictions.

Donna

Re: To Dr. Davis - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

BG CPed on 8/21/01 at 17:54 (057469)

Donna I know there are some bad stories on here regarding surg, pf release mostly. lengthen heel cord is one of the simplest and effective procedures for a good foot surgeon, and prob the fastest.
The Achille is extremely strong and has a big influence on gait and foot function. If you have tried stretching them for a long time and got poor results you could have boney block or just be one of those folks that is congenitaly tight and dont respond to stretching.

One way that may indicate is if you have your leg straight and you relax if your Dr tries to dorsiflex your foot while you are relaxed and not helping him or stiffening up and you only get to 90 degree or a little more. Then while holding foot in proper position if he has you flex your knee slightly and you gain several degrees it is most likely h-cords.

If it does not increase or very very little it could be boney blockage or some other osseous issue. This is not fool proff but it is an indicator that some will use as a type of field test to check. What happens is when your leg is straight and extended there is tension on the achilles. When you bend leg at knee it releases tension letting the ankle dorsiflex more (if the joints are free of blockage)

Sometimes it works some times it doesnt

Re: To Dr. Davis - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

Dr. Zuckerman on 8/21/01 at 18:01 (057473)

I agree with the stop with the functional correction and start
with the accommodative devices. I would put as much shocking
absorbing material in the foot that I could find. Plastizole and poron
are really good ones.

Alot of the labs could supply this with a cast. There are diabetic device
that would fit you requirements

I am not trying to rain on your parade but I just don't feel that functional is going to help you. I have seen and tried to help your foot type and just ended up with plastizole and may cork and leather. but plastic is bad very bad.

Re: To BG- Cped Dr. Davis - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

Donna SL on 8/22/01 at 05:41 (057512)

BG,

I think when my pod measured my ROM he had me lie on my stomach, and then had me bend my knee. He did it extended too. He put my foot in neutral first, and measured the ROM with some type of ruler type thing. I can't remember for sure if I had the 5 degrees of motion with my legs bent, or straight, but I think it was increased when they were bent. I'll have ask my pod when he gets back from vacation. I may need to stretch my achilles more.

I think if I stay in a shoe with some heel elevation, and could get some type of accomadative orthotic for the forefoot, I would be fine. The last couple of days I didn't even use tape with the spencos, and had no heel, or arch pain. Is it possible to get met/sesamoid relief without a functional orthotic? Pure padding doesn't always seem to work, except in some very selective shoes. I tried one of those hapad met pads, and they felt awful. Would a kinetic wedge , or one of those 2-5 met bars work in a accomadative orthotic? I'm not sure if they are the same type of thing.

I spoke with the physiatrist today that's been treating me, and he feels some of excessive instability in my feet is coming from the lumbar disc injuries I have, and will improve as my back heals. He also said as my intrinsic foot muscles get stronger that will help my gait too.

Thanks for your input on surgery. Do you know people personally who have had it done? I still would never never consider surgery for this, but was just curious. I'd get rocker soles if I was desperate. I would still be stuck with the stinky cavus foot structure anyway.

How's the OTC cavus foot orthotic coming along?

Donna

Re: To Zuckerman Ques on wt- bearing vs non-wt bearing cast cavus orthotics

Donna SL on 8/22/01 at 06:26 (057513)

Dr. Zuckerman,

I think I agree with you with the functional orthotics. They only seem to make things worse. My pods goal was to eventually get me out of them too. I just need to get a decent accomodative one that works.

Donna

Re: To Donna, Would this work for you?

Sean - C.Ped. on 8/23/01 at 15:56 (057703)

Just thinking out loud. Why couldn't you have an unconventional orthotic made with a soft top cover - say 35durometer eva with a medial side soft posting using 35durometer eva and a stiff lateral posting of 60durometer eva or cork (since you like cork, although the hardest durometer cork is 60) and then the valgus posting. You also might benifit from a heel lift in either the shoe or orthotic to help accomodate your equinus. You may have tried all this. If you have please forgive.
Cordially,
Sean
Ps. if you wanted more support on the lateral border you could modify the orthotic that has hard plastic by removing the hard plastic completely in the arch area and leaving small mount in heel area and lateral border and inserting a soft eva to support the arch but has some give also. We make a large amount of orthotics for diabetic patients and there are many times that we have to come up with ways to accomodate their specific needs. Most all the materials available are able to be used in conjunction with one another to produce the perfect orthotic for that patients needs.
Good luck.

Re: To Donna, Would this work for you?

Donna SL on 8/24/01 at 06:45 (057774)

Sean,

I really appreciate you thinking about this.

Do you mean just run a softer posting under the edge of the medial side of the orthotic shell, so there is some give, or sort of half it under the shell? I know that when my pod tried extending the lateral post just along the outside part of the orthotic towards the 5th met head it was too rigid, and my foot could not roll through the motion, so he had to move it back.

You got me thinking about something though. The very first pair of orthotics that I had made years ago contoured to my arch , yet they didn't seem to bother me in the arch area , even though they were a rigid plastic. The heel cups weren't that deep, and they didn't have any intrinsic valgus correction. They felt uncomfortable in the heels, because the plastic was hard as a rock, and they were a little narrow and flat in the heel area, but they didn't cause PF type heel pain, or seem to restrict my motion. I think they probably didn't have as much fill in the positive cast which resulted in a shallower heel cup area , yet still allowed the arch to contour to my feet. They did a good job of taking the pressure off my met heads.

I never really started having problems until pods started putting valgus posting intrinsically into my orthotics, and deepening the heel cups. All my pods orthotics make me feel like I'm too deep at the heel, and a lift doesn't seem to help. Also the deep heel cup pushes me out more especially the rise around the medial side of the heel which also seems to be restricting the motion , and that's when he heel and arch pain begins.

I'm starting to think that some of the problem is really coming from a combination of too deep of a heel cup , and maybe too much intrinsic valgus posting in the orthotic correction, and not so much from the arch area, even though it needs to be lowered somewhat. I'm wondering if the valgus correction was reduced, or removed, and there was just a small valgus post at the heel if that would be enough to support the lateral side of the foot. I read once that there should never be more forefoot valgus posting in the orthotic then the degrees someone can evert their foot on their own, regardless of how much forefoot valgus the person really has.

If I'm wrong, I like the idea of the compressible arch with the firmer plastic shell. Does that really work?

Hope I didn't confuse you. I'm starting to confuse myself. I know what I want to say, but don't know if I'm explaining myself correctly.

Donna

Re: Donna, Yes a met bar will relieve pressure

Sean - C.Ped on 8/24/01 at 14:53 (057843)

A met bar will relieve pressure on the met heads with or with out an orthotic at all. You can have a met bar placed on the bottom of a shoe to relieve pressure on met heads.
Good Luck,
Sean

Re: To Donna, Would this work for you?

Sean - C.Ped. on 8/24/01 at 15:08 (057845)

There is no exact right or wrong on how an orthotic should be made , what material it should be made of, or how parts of it should look. As long as the orthotic is addressing your needs, accomodating your concerns and helping you heal, that is all that matters.
I personally don't like to intrinsically post the orthotics that I build. With extrinsic posting I can shave it, or move it to fine tune the orthotic for that patients needs. Intrinsically posted orthotics cannot easily be adjusted to meet your needs.
How deep is your typical orthotic heel cup. I try to make most (not all shoes will allow,and some patients do not like a deep heel cup) of my heel cups about 1/2'-3/4' deep. That is from the inside bottom of the heel cup to the top back edge of the cup.
Also, I read somewhere in one of your other posts where you have only 5 degrees ROM. Why NOT have rocker soled shoes. They can be a tremendous help to patients with that little ROM. Honestly, it all depends on the expertice of the practioner.
Good Luck
Sean

Re: To BG - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

bg cped on 8/19/01 at 21:51 (057211)

That depends on what he is doing. If it is standard bio-foam squish box. That is similar to that soft styrene type foam they use in flower pots. You can get good results with that method but it is dependent on the skill of the one taking cast.

If you have a rigid cavus foot sometimes semi wt bearing is good method in foam. You can grind under arch to make it less firm. you can fill the arch in the cast. did they post the fo on the lateral border? how did your foot respond when/if that was done? what is your main symptomand did certain things work better or worse?

I know it is confusing, it is also hard to explain how to make it correctly. I can do them in my sleep when I have the person there but there is no set way to describe it to someone else.

Re: To BG - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

Donna SL on 8/20/01 at 03:48 (057230)

Hi BG,

Thanks for responding so quickly.

The orthotic my pod recently made did have a reinforced lateral border. He used birkocork to reinforce the lateral side, and it worked very well in
controlling my supination. Without it the eva shell wasn't strong enough to control the supination. But, without strong midfoot support normally
provided by a higher arch I starting rolling onto my big toe joint, and had more pressure on the forefoot in general. Also the softer arch support causes the fascia to feel stressed and strained, yet I can't take anything pressing on my arches. To even out my metatarsals, and to take care of the plantar flexed first ray my pod has intrinsic valgus posting in the orthotic, which seems not work if the material is too soft. He was thinking of reinforcing the forefoot areas with a liquid thermoknit, but I think he would be patching it up all over the place with this stuff.

The one problem with the cavus foot theory for me anyway is that if you post the lateral side of the foot, it is now going to cause the foot to pronate in the mid or fore foot stance. How do you keep from driving the first ray into the ground if there is a plantar flexed ray involved, which makes the arch sort of feel like it's collapsing if the arch on the orthotic is to low, or too soft, because now the medial side is not balanced off the lateral side? Also, if too soft of a material is used it seems unable to take pressure off the met heads. Just putting a recess under the first met doesn't seem to work, and just causes the first ray to be driven further into the ground, because it causes more forefoot pronation.

How can a functional orthotic work if most of the shell is too soft, or the arch is too low? What's left to control the foot? Also an ankle equinus which I have even complicates things more. It really seems like a traditional orthotic shell made out of a singe density material can't really work for a cavus foot, unless maybe it's reinforced in various areas. Most traditional neutral balanced Rooterian orthotics seem to work by off loading the weight onto the arch, and/ or depend on deep heel cups for control - which neither can really be tolerated in most cases by a cavus foot with an ankle equinus. It seems like a different design is needed.

I was just wondering what the magic of a semi-wt bearing cast could provide that this orthotist is talking about. Unless the orthotist isn't using a traditional orthotic design. Tonight I found an article in the O and P library that describes a non traditional orthotic for hyper pronated feet, and I'm wondering if the orthosis he would be using is based off the same theory , but with with cavus foot modifications. He said he would use soft materials. The article mentions something about the 3 point system. Maybe you could comprehend it better than me.

http://www.oandp.org/jpo/library/1997_02_077.asp

I could ask my pod to get a foam casting box. He's really open to anything if you felt the semi wt bearing method is more advantageous. I don't peronally see how much could be changed with the foot in a semi wt-bearing position. If this 3 point system method isn't some fancy method, and it's just a matter of getting the foot in neutral while in the box, I'm sure my pod could cast me this way, but am wondering if it would solve any problems, without changing the traditional orthotic design itself like adding a medial border to stop the foot from rolling in to compensate for the lower arch height, reinforcing other bits of the orthotic, etc.

Donna

Re: To BG - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

Ed Davis, DPM on 8/20/01 at 14:49 (057293)

One of the weight bearing or semi-weight bearing methods is more likely to work for a cavus foot than for a 'flat' foot.

You are correct about a 'general' lateral wedge or post inducing additonal pronation or arch strain. I have not examined your foot but, by description (if I can do some guessing) you are suggesting that you have a cavus foot with a rigid forefoot valgus foot type (generally includes a plantar flexed first metatarsal) coupled with some compensatory subtalar joint pronation.

Use of a semi-rigid orthotic (emphasis on 'semi') casted non-weight bearing, possibly with a plantar fascial groove in the device, the device molded 'tight to cast' (minimal plaster fill on the positive cast) but with the subtalar joint in mild pronation may be the way to go. Only the FOREFOOT is posted in valgus---as such, no subtalar joint pronation is induced but there is pronation of the midtarsal joint around its longitudinal axis (supination of the midtaral joint around its longitudinal axis is the proximate cause of plantar fasciitis while subtalar joint pronation is often the underlying culprit that induces such motion). The feeling of the first metatarsal being 'driven into the ground' will not occur since the forefoot valgus post allows a GRADUAL distribution of forefoot pressure away from the first MTP joint.
Ed

Re: To Dr. Davis - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

Donna SL on 8/20/01 at 17:28 (057320)

Hi Dr Davis

I had a orthotic that induced slight pronation, and I think the design was similar to what you were describing with valgus posting, and the effects were devastating , and I'm still recovering from them. That design twisted my foot like a pretzel, and caused severe pain, and inury. I'll show my pod your post next time I see him in case I'm wrong, although I doubt it. He's familiar with all my old orthotics.

My current pod says I'm an excessive supinator, and very laterally unstable, and my foot needs varus wedging. I'm looking at some old notes he wrote, and it says my foot needs major support through the calcaneal cuboid, and the cuboid fifth metatarsal area to help stabilize the foot. He also mentions that I have a plantar flexed first ray of 0 -2 degrees. He did a coleman block test, and said it's not fixed. The right foot supinates much more than the left. Also, he says I only have a slight forefoot valgus. He said the only reason it appears that I'm pronating is due to the foot being unstable laterally, and that I have contact phase supination that then leads to late mid-stance pronation. The less I roll out then the less I'll roll back in. He told me I do not have any abnormal pronation at the calcaneous area/ subtalar joint at all. The slightest bit of anti-pronation control only makes this worse. My foot is like the one described in the cavus foot article in the biomechanics magazine. My pod invented a special inverted device for severe pronators, so I feel confident he knows I can't take any type of anti-pronation control, because he's seen and treated so many feet opposite of mine. He said none of my prior orthotics had any lateral support.

He originally tried the lateral design approach with semi rigid plastic. I couldn't tolerate it, because the plastic seemed too hard on the arch, and heel even with a spenco/poron top cover. He put a plantar fascia grove in that didn't help either. He says he used a slight fill in the arch, but it doesn't appear so to me. The device killed my arch, fascia, and heels. He also has intrinsic valgus posting in his design. I think the pain I felt throughout the foot especially the heels was due more to the stress on the foot, and irritation of the nerves from struggling to get over the high arch than the plastic, because I've tolerated plastic before in a non controlling orthotic with a flatter arch. The same design made out of EVA felt even worse, I only have around 5 degrees of ankle dorsiflextion, and the high arch seems to make it more difficult for me to walk. It puts stress everywhere. I don't think he was aware of the ankle equinus when he first started with me, but is now. I can't tolerate a deep heel cup either because it presses on my nerves that are still recovering from entrapment of both the lateral plantar nerves, and the first branch, that runs right along the medial
side of the heel.

The design only became somewhat tolerable when he lowered the arch, and used a softer material. Also, when he reduced the arch he was able to reduce the lateral support, because the medial arch didn't push me out as much. I do prefer a flexible plastic because it feels more stable, but could only tolerate in on the heels if there was a very soft pad, which might jeopardize the stability in the heel. Also it couldn't press on the arch area either.

Should I give up? Only kidding. I'm curious though why you feel a semi-wt bearing cast would be more beneficial for a cavus foot. The orthotist I just saw is so busy that it takes 2 to 3 weeks to get an appointment each time, so I really prefer to stick with my pod. I'm just thinking it might be worth the wait, because maybe the orthotist are approaching this whole problem at a different angle, and the orthotic design they are using is unique, and there is more to it than just using a semi-wt bearing cast.

Hope I didn't confuse you with this long post. I appreciate any continuing thoughts you may have on this.

Donna

Re: To Dr. Davis - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

Ed Davis, DPM on 8/20/01 at 20:32 (057351)

I am unsure about a number of things you mentioned in the second paragraph.
If you are an excessive supinator, why do you need varus wedging? What is the reason attributed to the late midstance pronation (assuming you are refering to subtalar joint pronation)? Excessive late midstance pronation?

You are correct about the lack of ankle dorsiflexion being a problem. Individuals with high arches need even more dorsiflexion than those with low arches. You may find only fair orthotic tolerance until you stretch out your gastrosoleus achilles complex, despite the manner in which the orthotic is made.

Feet which are rigid or semi-rigid cavus foot types deform less on weight bearing and that is the reason why weight bearing or semi-weight bearing techniques offer a more better 'capture' of that foot type than say, a flexible flatfoot which looks very different weight bearing than not. Despite that, I still prefer the non-weight bearing prone casting technique.

At this point, I would really need to examine your feet before I could accurately sort out the information provided. I have to admit that you have really piqued my curiosity as the info. is not totally 'adding up.' If you come to the Seattle area, I would be willing to make you an orthotic which you would only pay for if it definitely worked-- you would make the decision if it is successful or not.
Ed

Re: To Dr. Davis - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

BG CPed on 8/20/01 at 21:03 (057358)

I also noticed the 'varus' notation. What I have seen and what Dr Davis is talking about (I think) is tight gastroc/limited dorsiflexion will cause or try to cause your foot to pronate. This is because you are not getting the motion from your ankle. Many folks with tight gas will turn feet out a little, this allows the the body to pass over the foot without the ankle dorsiflexing much. If you are tight and try to walk with your toes pointing straight ahead, most likely your heel will bounce or lift premature.

If you have a plantarflexed 1st and a forefoot valgus. you cant push your 1st thru the floor so it want your forefoot to supinate and the rearfoot want to pronate, As Dr Manoli says it is like twisting a wash rag. You have a type of push me pull me going on in your foot. If the arch is too high or hard, and depending on how the forefoot and or rearfoot is posted you cancause the arch to be uncomfortable. Many folks dont give enough consideration to the relation of forefoot to rearfoot mechanics, one will influence the other. Many just make a hard device with a very high arch and a little dab of post under heel. I works for some but is not good for true cavus foot.

I see several per week that have cavus and are told they pronate. I think this is due to tight gastroc and equinus that present in this foot. They may have some mid to late stance pronation, but the foot is still cavus, they see it collapse some an say 'yep thats pronating' what they are seeing is the rearfoot/gastroc overcoming the forefoot structure, like the twisted wash rag.

Another common mistake I see is a cavus foot with a lateral wedge under the heel, this can cause many problems and is not indicated in the majority of cases. Donna has any of your Doctors done a Coleman Block test on you? it is VERY simple and is an easy way to see if you would be helped by a cavus device. Also if you have peek-a-boo heels, this is another indicator.

Dr Davis I see you are near Seattle, You must know Dr Smith at Northwest Pod . I know Lisa and a few others from there. They are the only Lab I use when I dont make them myself.

Re: To Dr. Davis - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

BG CPed on 8/20/01 at 21:14 (057359)

Donna my bad, I did see that he did a Coleman on you. The question I left out (phone rang)was if you look at the Coleman test. It corrects the foot with no arch at all, it is a piece of wood. You indicated that he reduced the medial arch, and reduced valgus post at same time, did he try to leave the valgus alone first?

Dont want to confuse you and I dont want to make your Dr strangle you. Just a thought...now you can see why we wrote that paper, there are more of you around than most practitioners think. I had 2 more today that were treated same way, fixed both up very well

Re: To Dr. Davis - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

Ed Davis, DPM on 8/20/01 at 21:54 (057367)

Yes, I am familiar with Dr. Smith and use his lab.
Donna claims a low degree of forefoot valgus but I really have to wonder about that measurement. Forefoot supinatus, that is a forefoot position distorted by excess supination at the longitudinal axis of the midtarsal joint, falsely increases the amount of forefoot varus measured or decreases the amount of forefoot valgus measured. I have to wonder if that is what is going on with Donna. I attempt to 'cancel out' any forefoot supinatus when casting for orthotics by manually pressing down on the first metatarsal head--- Paul Scherer, DPM of Prolab (San Francisco) teaches this and has a lot of good educational material on this subject.

It is really the midtarsal joint longitudinal axis supination in late midstance that strains the plantar fascia, particularly notable in individuals with equinus---bringing the first ray down while taking the orthotic cast really helps in such cases.
Ed

Re: To Dr. Davis - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

Ed Davis, DPM on 8/20/01 at 22:00 (057368)

PS Agree with you about the lateral wedge under the heel--avoid, avoid.
Another thing to look for in Donna is calcaneal varus and my guess-limited STJ eversion ROM available. Somewhat tough to control--would use deep heel cup with only a few degrees of varus in heel post. This may not be a big issue though because she spends little time on heel with her equinus.
Ed

Re: To Dr. Davis - i meant valgus posting

Donna SL on 8/21/01 at 04:34 (057397)

Dr Davis,

Opps my error. I guess I meant a valgus wedge to control the varus. It's along the the lateral side of the orthotic.

As far as the late stance pronation, that's what I was trying to explain in my previous post, about rolling out, then rolling in. Try to imagine the foot like a see saw moving laterally to medially. The arch doesn't really collapse. It seems to stay rigid. The whole foot will start to tilt in at late stance after excessive contact supination. The forefoot pronation seems to only bother me in my right foot, because that one supinates more. My left foot seems to be taking more stress though. I can feel how supinated I am, and my peroneals get so irritated if I don't at least have some type of lateral wedge in a shoe, and this also has affected my back. I wish I could show you what I mean.

There is also some discussion in the podiatry uk mail board about supination
http://www.mailbase.ac.uk/lists-p-t/podiatry/
A bunch of pods from all over the world have all kinds of podiatry discussions, mostly about biomechanics. In an older thread called Supination Therapy they talk about this foot type, and they give various reasons why this foot type exist, and suggest treatment They make their treatments sound so easy to implement.

I've been stretching like crazy, and I think I was even worse than this before. My chiropractor has helped me gain a few degrees of dorsiflexion
through ART, and ankle manipulations. I recently read an article in JAPMA written by a DPM named Howard Dananberg, who claims he can dramatically increase dorsiflexion. Are you familiar with his methods, and know if they really work? I know an equinus can make orthotic therapy difficult. Even if I wear an athletic shoe, I need to add a small heel lift, or it feels like I'm walking out of quicksand in my rear foot. The heel lift of
course puts more pressure on the forefoot. All the orthotics make me feel even worse even with a little heel lift. I can't seem to stand a negative heel feeling, which seems to occur in any functional orthotic. They all start to trigger the heel, and arch pain again. It appears that with an ankle equinus more weight is put on the heels.

In reference to your following post on casting my pod had been a highly respected professor in biomechanics for many years at CCPM, and also
has been in practice for almost 24 years. I feel confident he takes a perfect neutral cast, and knows what he's doing in that respect, and removed all supinatus from the cast. I live in San Francisco, and have had some other biggies from CCPM take good cast, and also had some cast taken that were horrendous.

I also spoke to Dr. Schere a couple of months ago. I had called him, because he had written an article in Podiatry Today, and he seemed to
understand my type of foot, but he said he couldn't see me, because he's retired from private practice. He said he doesn't understand why so many
pods don't know how to recognize, and treat this foot type.

As far as the valgus measurement my current pod extensively checked, and rechecked all my measurements. He said he could not believe the other
pod's measurements had an 8 degree forefoot valgus, that he insist is absolutely incorrect, and the valgus is very slight.

I've improved so much since I haven't been wearing any of their functional orthotics, yet I'm still not really comfortable, because I still don't have an orthotic that is even somewhat accommodative. In the interim I've been wearing otc spenco orthotics with tape for stability, and heel lifts with some lateral wedging in the shoe which isn't great, but is better than nothing. I'm just at the point where I can't stand taping anymore, and my metatarsals seem to be getting worse wearing the spencos, even though my heel and arch pain has improved greatly. I still need to stay on meds though. Also, even with insurance it's cost me a fortune in both time and money, and I have no orthotic to show for it.

If I ever come up to Seattle I'm going to take you up on your offer. You may have more of a challenge than you think, or maybe you'll solve all my
problems. I had read that Northwest labs can vary the flexibility in various parts of the orthotic which is what I think I need, but again it doesn't seem like they can be adjusted. I can't even ask my pod about the semi wt bearing casting right now, because he will be out of town for 3 weeks. I don't know if I will get much more accomplished with him at this point anyway. I'm getting tired of giving him cavus foot lessons. Also, I can't get an appointment with the orthotist until mid September. I can't believe this is such a hard problem to solve. It seems to me someone is missing something.

Dr. Davis, I can't thank you enough for the input you have given me so far, and that wonderful offer.

Donna

Re: To BG cped Dr Davis - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

Donna SL on 8/21/01 at 05:43 (057400)

Hi BG,

I had posted to Dr. Davis earlier that I made an error, and meant a valgus post, not a varus post.

I'm confused about your Coleman block question. If you mean if I stand on the block, and the varus corrects then that is true. But what do you mean by no arch at all? My arch stays up, and I've had the test with nothing under the arch. Do you mean having the test with something under the arch?

As far as the lateral post. At first my pod had a high medial arch, and a high lateral post. I was still supinating over the lateral post when he used a softer material, and my foot just abducted all over the place with a semi-rigid plastic. He also had a very deep heel cup which also exerts an anti-pronation force.

I then asked him to lower the arch, because I referenced your article that said a high arch doesn't let the foot pronate. I noticed the high arch keeps the foot from pronating at the heel which is the area I need to pronate at. When he lowered the arch, he knew he had to lower the lateral side so I would be in balance. The lower arch, lower medial post combo was much more effective in controlling the supination then the high arch, big lateral post combination, because I wasn't fighting the high arch. The control worked better in both plastic, and EVA. He had tried lowering only the medial side in the past leaving the lateral side as is, and it caused pain on my first met.

I'm just wondering if he had redone the cast with maximum arch fill to lower the arch rather than grind it out of the orthotic itself to flatten the arch I would have a more supportive orthotic, and not have all these problems. He made it so thin that there is no support left in the midfoot, or forefoot. The forefoot valgus correction can't work, because the orthotic shell was only made out of a 30 durometer EVA to begin with, and the forefoot needed to be thinned when he thinned the arch out.

This weekend I did some additional research, and I have read over, and over again that there should be extra medial expansion in the positive cast, by pods who were familiar with treating cavus, laterally unstable feet. I've mentioned this to my pod many times before, yet he has yet to change the cast itself. I have the cast at home, and am debating if I should just take the cast to another orthotist technician I know who has a lab, and let him fill the medial arch, and repress a new pair of orthotics over them. He said he could duplicate the cast and work on the duplicate. My pod has been so reluctant to do this in the past, because he seemed worried about how much to reduce the arch, and was just playing around with the orthotic instead.

At this point it's hard to know if I'm getting arch strain from the orthotic shell being so unsupportive, or from too much lateral correction. The only part that is left that is strong is the lateral side that's been reinforced with birkocork. There's not much left of the rest of the shell.

I agree there are a lot more of us around then most pods seem to realize. I see tons of people walking on the outside of their feet.

Donna

Re: To Dr. Davis - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

Dr. Zuckerman on 8/21/01 at 11:10 (057423)

Hi,

I have found that there even if you completely evaluate the need for orthosis with a gait analysis and biomechanical evaluation there are just some feet that can't tolerate the orthosis. Having a pes cavus with ankle equinus is one of them. You may need to take a look at lengthening the achilles tendon to remove the equinus. In addition the ankle joint needs to be evaluated for any boney restrictins.

You have a very tough foot structure that is very very difficult to treat with orthosis

Re: To Dr. Davis - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

Donna SL on 8/21/01 at 13:38 (057442)

Dr Zuckerman,

I agree some people can't tolerate orthotics with both high, and low arches. I just wonder sometimes, if it was because they weren't prescribed the proper orthosis. I tolerated orthosis for over five years before I was put in the wrong one. The one I had prior was sort of between an acommodative and functional orthotic, and it never caused any injuries, and provided a tolerable amount of comfort.

The closer the I've had my pod get back to that type of correction the more tolerable the orthosis becomes. I've just had such a hard time in the past convincing these Rooterian purist that not everyone can tolerate being corrected to neutral, and just try to accommodate the uncomfortable spots in the foot, and use maybe half the correction, even if it seems a little unconventional. I may be better off finding someone that has worked with diabetics, and geriatrics, who is more familiar with accommodating the foot, instead of trying to correct it so perfectly. I think that was the attitude of the orthotist I met last week, but need to speak with him more.

The more I heal, the more I can get around mostly taping, and using OTC spencos, and lateral wedges, with mainly just forefoot discomfort. This convinces me that I could benefit from some type of an accommodative orthotic.

Thanks for the suggestion, but there is no way in he world I would consider any type of surgery for lengthening the achilles tendon after what I've read on this board. As far as bony blocks would that have shown on a MRI, or x-ray which I've had? They all appeared normal. How else is this evaluated? My chiropractor didn't think I had any bony restrictions.

Donna

Re: To Dr. Davis - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

BG CPed on 8/21/01 at 17:54 (057469)

Donna I know there are some bad stories on here regarding surg, pf release mostly. lengthen heel cord is one of the simplest and effective procedures for a good foot surgeon, and prob the fastest.
The Achille is extremely strong and has a big influence on gait and foot function. If you have tried stretching them for a long time and got poor results you could have boney block or just be one of those folks that is congenitaly tight and dont respond to stretching.

One way that may indicate is if you have your leg straight and you relax if your Dr tries to dorsiflex your foot while you are relaxed and not helping him or stiffening up and you only get to 90 degree or a little more. Then while holding foot in proper position if he has you flex your knee slightly and you gain several degrees it is most likely h-cords.

If it does not increase or very very little it could be boney blockage or some other osseous issue. This is not fool proff but it is an indicator that some will use as a type of field test to check. What happens is when your leg is straight and extended there is tension on the achilles. When you bend leg at knee it releases tension letting the ankle dorsiflex more (if the joints are free of blockage)

Sometimes it works some times it doesnt

Re: To Dr. Davis - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

Dr. Zuckerman on 8/21/01 at 18:01 (057473)

I agree with the stop with the functional correction and start
with the accommodative devices. I would put as much shocking
absorbing material in the foot that I could find. Plastizole and poron
are really good ones.

Alot of the labs could supply this with a cast. There are diabetic device
that would fit you requirements

I am not trying to rain on your parade but I just don't feel that functional is going to help you. I have seen and tried to help your foot type and just ended up with plastizole and may cork and leather. but plastic is bad very bad.

Re: To BG- Cped Dr. Davis - Cped Ques on wt- bearing vs non-wt bearing cast cavus orthotics

Donna SL on 8/22/01 at 05:41 (057512)

BG,

I think when my pod measured my ROM he had me lie on my stomach, and then had me bend my knee. He did it extended too. He put my foot in neutral first, and measured the ROM with some type of ruler type thing. I can't remember for sure if I had the 5 degrees of motion with my legs bent, or straight, but I think it was increased when they were bent. I'll have ask my pod when he gets back from vacation. I may need to stretch my achilles more.

I think if I stay in a shoe with some heel elevation, and could get some type of accomadative orthotic for the forefoot, I would be fine. The last couple of days I didn't even use tape with the spencos, and had no heel, or arch pain. Is it possible to get met/sesamoid relief without a functional orthotic? Pure padding doesn't always seem to work, except in some very selective shoes. I tried one of those hapad met pads, and they felt awful. Would a kinetic wedge , or one of those 2-5 met bars work in a accomadative orthotic? I'm not sure if they are the same type of thing.

I spoke with the physiatrist today that's been treating me, and he feels some of excessive instability in my feet is coming from the lumbar disc injuries I have, and will improve as my back heals. He also said as my intrinsic foot muscles get stronger that will help my gait too.

Thanks for your input on surgery. Do you know people personally who have had it done? I still would never never consider surgery for this, but was just curious. I'd get rocker soles if I was desperate. I would still be stuck with the stinky cavus foot structure anyway.

How's the OTC cavus foot orthotic coming along?

Donna

Re: To Zuckerman Ques on wt- bearing vs non-wt bearing cast cavus orthotics

Donna SL on 8/22/01 at 06:26 (057513)

Dr. Zuckerman,

I think I agree with you with the functional orthotics. They only seem to make things worse. My pods goal was to eventually get me out of them too. I just need to get a decent accomodative one that works.

Donna

Re: To Donna, Would this work for you?

Sean - C.Ped. on 8/23/01 at 15:56 (057703)

Just thinking out loud. Why couldn't you have an unconventional orthotic made with a soft top cover - say 35durometer eva with a medial side soft posting using 35durometer eva and a stiff lateral posting of 60durometer eva or cork (since you like cork, although the hardest durometer cork is 60) and then the valgus posting. You also might benifit from a heel lift in either the shoe or orthotic to help accomodate your equinus. You may have tried all this. If you have please forgive.
Cordially,
Sean
Ps. if you wanted more support on the lateral border you could modify the orthotic that has hard plastic by removing the hard plastic completely in the arch area and leaving small mount in heel area and lateral border and inserting a soft eva to support the arch but has some give also. We make a large amount of orthotics for diabetic patients and there are many times that we have to come up with ways to accomodate their specific needs. Most all the materials available are able to be used in conjunction with one another to produce the perfect orthotic for that patients needs.
Good luck.

Re: To Donna, Would this work for you?

Donna SL on 8/24/01 at 06:45 (057774)

Sean,

I really appreciate you thinking about this.

Do you mean just run a softer posting under the edge of the medial side of the orthotic shell, so there is some give, or sort of half it under the shell? I know that when my pod tried extending the lateral post just along the outside part of the orthotic towards the 5th met head it was too rigid, and my foot could not roll through the motion, so he had to move it back.

You got me thinking about something though. The very first pair of orthotics that I had made years ago contoured to my arch , yet they didn't seem to bother me in the arch area , even though they were a rigid plastic. The heel cups weren't that deep, and they didn't have any intrinsic valgus correction. They felt uncomfortable in the heels, because the plastic was hard as a rock, and they were a little narrow and flat in the heel area, but they didn't cause PF type heel pain, or seem to restrict my motion. I think they probably didn't have as much fill in the positive cast which resulted in a shallower heel cup area , yet still allowed the arch to contour to my feet. They did a good job of taking the pressure off my met heads.

I never really started having problems until pods started putting valgus posting intrinsically into my orthotics, and deepening the heel cups. All my pods orthotics make me feel like I'm too deep at the heel, and a lift doesn't seem to help. Also the deep heel cup pushes me out more especially the rise around the medial side of the heel which also seems to be restricting the motion , and that's when he heel and arch pain begins.

I'm starting to think that some of the problem is really coming from a combination of too deep of a heel cup , and maybe too much intrinsic valgus posting in the orthotic correction, and not so much from the arch area, even though it needs to be lowered somewhat. I'm wondering if the valgus correction was reduced, or removed, and there was just a small valgus post at the heel if that would be enough to support the lateral side of the foot. I read once that there should never be more forefoot valgus posting in the orthotic then the degrees someone can evert their foot on their own, regardless of how much forefoot valgus the person really has.

If I'm wrong, I like the idea of the compressible arch with the firmer plastic shell. Does that really work?

Hope I didn't confuse you. I'm starting to confuse myself. I know what I want to say, but don't know if I'm explaining myself correctly.

Donna

Re: Donna, Yes a met bar will relieve pressure

Sean - C.Ped on 8/24/01 at 14:53 (057843)

A met bar will relieve pressure on the met heads with or with out an orthotic at all. You can have a met bar placed on the bottom of a shoe to relieve pressure on met heads.
Good Luck,
Sean

Re: To Donna, Would this work for you?

Sean - C.Ped. on 8/24/01 at 15:08 (057845)

There is no exact right or wrong on how an orthotic should be made , what material it should be made of, or how parts of it should look. As long as the orthotic is addressing your needs, accomodating your concerns and helping you heal, that is all that matters.
I personally don't like to intrinsically post the orthotics that I build. With extrinsic posting I can shave it, or move it to fine tune the orthotic for that patients needs. Intrinsically posted orthotics cannot easily be adjusted to meet your needs.
How deep is your typical orthotic heel cup. I try to make most (not all shoes will allow,and some patients do not like a deep heel cup) of my heel cups about 1/2'-3/4' deep. That is from the inside bottom of the heel cup to the top back edge of the cup.
Also, I read somewhere in one of your other posts where you have only 5 degrees ROM. Why NOT have rocker soled shoes. They can be a tremendous help to patients with that little ROM. Honestly, it all depends on the expertice of the practioner.
Good Luck
Sean