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For Richard Question re: arch supports

Posted by Tina H on 1/26/05 at 21:01 (168014)

Hello Richard, My 14 year old daughter was just diagnosed with PF. She has really high arches. I purchased Powersteps for her but they don't match her arch at all. Her arch is much higher. I do have an order for her to get custom made orthotics, but as we all know sometimes they work and sometimes not. I wanted to try a premade first. Do you know of any with a higher arch than powersteps? Thank you, Tina

Re: For Richard Question re: arch supports

Richard, C.Ped on 1/27/05 at 11:26 (168034)

Not really. Power steps have about the highest I have seen. I just took care of a 15 year old girl with very high arches. She also tried powersteps. If you talk to a C.Ped or doc about orthotics, I made hers (and most other high arch feet) out of EVA. I used 40 durometer 1/2' for posting, and 30 durometer 1/8' for the shell. She is having no problems at all.

Where ever you go, if you decide to get custom, check to see if there is a warranty. I warranty all custom items for a year. That means, If there are any adjustments or repairs (due to normal wear and tear, not if the dog gets them..haha) I fix or replace free.

Check your insurance to see if orthotics are covered. If they are, find a provider who will file first, then bill later.

If you talk to someone,and have any questions about what they told you, please let me know. I will be happy to help. You wouldn't be in South Carolina, North Carolina or Georgia by chance?? I have to ask...you never know.

Re: For Richard Question re: arch supports

Tina H on 1/28/05 at 09:06 (168082)

Richard, wish we were in your area. I know you would do a good job with this. We are in North Pittsburgh. It's so heart breaking having a child with this condition. She's a good runner but I can see the writing on the wall for that. I've told her she most likely will have to skip track this spring, but it will kill her if she cannot continue to play field hockey. My goal is to help her at least be able to do that.
Okay so the diagnosis was pf and pes cavus(mild). The order for orthotics-
'custom molded foot orthotics 1/8inch lateral heel wedge (... some word I can't read la...) arch support, plastizole lined. She referred us to a company called union orthotics.
The pediatric orthopedist we saw admitted she didn't know much about pf becasue she doesn't see it very often and told us if we wanted to follow up on this we should see another doctor, an orthopedist who specializes in feet.
I know she needs arch supports, now that it's been pointed out to me just how high her arches are. The money is an issue here, in that I don't want to just waste $500- but more importantly, comfort and effectiveness are the main concerns. I want my daughter to be able to do at least some of the things she's enjoyed with her friends and not become a couch potatoe. Thanks, and sorry this is so long, it's just very sad and scary when this happens to your child! Your advice is certainly appreciated. Thank you, Tina H

Re: For Richard Question re: arch supports

Richard, C.Ped on 1/29/05 at 16:34 (168136)

I can sense your frustration. My wife has family in Pittsburgh, but I do not know of a good pedorthist there. I am not sure if I would use plastazote. I have with athletes before, and it seems to break down very quick.

If you don't mind, please email me. I want to talk about something with you (or in Pittsburgh talk, you guys...lol).

(email removed)

Re: For Richard Question re: arch supports

Tina H on 1/30/05 at 06:35 (168160)

Thanks Richard. By the way it's 'yinz' here which cracks me up. We are not from Pittsburgh, so it sounds so funny when you leave a store and the cashier says 'Yinz have a good day'. Of course I was raised in the PA dutch area and we have our own weird ways of saying things like putting adjectives behind nouns and ending sentences with prepositions and then there are those german words that have made it into the vocab like, 'red' up your room (means clean up your room). LOL Tina

Re: For Richard Question re: arch supports

A Manoli MD on 2/13/05 at 20:13 (169015)

sorry i'm late in coming in here.

who decided that a high arched foot needs an arch support? this is an outmoded idea that contines to be passed down from generation to generation. Whitman, Scholl and others started molding the orthotic to fit the arch, but it only keeps the stiff foot from everting more ('pronating,' if you must).

we treat this type of foot with a lateral forefoot post, dropping the 1st metatarsal head into a depression. the ARCH IS ACTUALLY LOWERED (sacrireligious, we know). but, this allows the stiff foot to evert and absorb shock.

this was written up a few years ago, FYI:


we also have a review article on the subject coming out in the March, '05 Foot & Ankle International.

DISCLAIMER: Brian Graham, C.Ped, and i have designed and patented this device for mass production, and it should be available through djOrtho (Vista, CA)in the next few months. we are introducing it at the American Academy of Orthopaedic Surgeons, Annual Meeting, in Washington, DC, next week.

it should be very useful for those that don't have the capabilities to custom fabricate them. or for those that don't know what to do. as it doesn't stroke the arch, it can be off-the- shelf.

a lateral heel wedge alone, as in the prescription under discussion, simply drives a plantarflexed 1st ray into the ground harder, if that's the case.!!

PS: we lived in Pittsburgh for 2 years. enjoyed the 'my hair needs washed' phrases. the locals all said the 'to be' was just understood.

Re: For Richard Question re: arch supports

Dr. Z on 2/13/05 at 21:16 (169018)

Dear Manoli,
I agree 100% with your accessment and findings with a high arched foot type and treatment.. They lack the ability to adapt or pronate to the ground. I can't count the patients that come to my office with hard inserts in their hards complaining of more pain from these device.
Gait and biomechanical evaluation reveal lack of subtalar joint pronation, equinus, and rearfoot varus.
My only orthosis treatment that I know to use is a heel lift, gel antisox type insert or plastizole and posting. I look forward to trying your new insert

Re: For Richard Question re: arch supports

elliott on 2/14/05 at 22:50 (169066)

Dr. Manoli,

It is reasonably well known that a cavus foot is harder to deal with--no argument on that--and I read your link, but many with that type of foot do well with a soft custom orthotic that fills in the arch. Given it's soft, rather than call it an arch support I'd call call it a form-fitting orthotic, with the arch having more cushioning than the rest of the orthotic and so promoting the necessary flexibility there. The main drawback of soft orthotics is that they wear out too fast.

Are you going as far to say that a flat cushioned OTC insert is better than a soft custom that fits the arch? I will point out that the symptomatic cavus foot often has trouble walking barefoot, perhaps suggesting the soft custom is superior. As an aside, I think I recall a study many years ago on the cavus foot that found, counterintuitively and for reasons unkown, hard custom orthotics to be superior to soft! Can't recall if it was a study on runners, PF, or what.

While I'm talking to you, can I ask you a question about the other foot type? I just had surgery for adult acquired flat foot two weeks ago and currently am at home recovering. One of the procedures involved lowering the first ray. My question to you is, which do you prefer for this, the (opening wedge) medial cuneiform osteotomy or fusion of the first TMT joint? I had conflicting opinions, with each doc claiming the other procedure is more likely to result in arthritis of the neighboring joints. A little late for me now, but hey, man, I gots to know! Thanks.


Re: For Richard Question re: arch supports

A Manoli MD on 3/05/05 at 20:18 (170546)

thanks, elliott. i've been away and haven't looked at the site until today.

when i do our double heel osteotomy (medial calcaneal slide, and lateral column lengthening) for stage 2 posterior tibial tendon insufficiency MOST of the time the 1st metatarsal actually comes down by itself. i think it is due to the long peroneal tendon tightening as the lateral column is lengthened. the arch returns, too, and we attribute this to a tightening of the long plantar ligament with the lcl.

if there is still some residual supination of the 1st ray, i've done a few different things. if the joint is arthritic, i will fuse in in a plantarflexed position, sometimes with a small wedge graft. if i really need some medial stability, as is hyperelastic people, or those whose ankle is tipping into valgus, i will do this and also add a naviculocuneiform fusion. i've also done a number of simple opening wedge osteotomies of the base of the first metatarsal, and put in a wedge of bone (3-5mm) that i took from the iliac crest when i took the lcl graft. if you fix this with a screw it heals the best of all of them.

i was on a panel with dr. jeff johnson from st. louis in washington, DC last week, discussing this very thing. he has been doing the opening wedge thru the medial cuneiform that you mentioned, and showed some very nice results. i haven't done that, but, as you can see, the residual supination can be dealt with in a number of ways.

i really don't think that i would base my decision on the possibility of future adjacent joint arthritis, but rather i would choose depending on the durabilty/stability of what you want to accomplish, and the ease of healing the construct. i have a large number of very large men (>250#)from the early days, where we did not address the the medial joint 'sag' with a fusion. to date, i have not had to go back and fuse any of them for any medial symptoms. those joints are difficult to fuse in large people, and it does add a lot of foot stiffness.

i would like to see the hard arch support in cavus study you referred to. i don't recasll it. our philosophy is that a high-arched foot doesn't usually need an arch support. i see a large number of people made much worse with them, and the common idea is that if it isn't working, people simply MAKE THEM HIGHER! surely, there are some people with cavus are very used to the hugging effect of the supports and demand them.

cushion is better than noncushion, in general.

our new device is for those with a plantarflexed 1zt ray, who correct with the coleman block test, indicating forefoot-driven-hindfoot-varus that is supple. we drop the sesamoidal area into a depression, and use a lateral forefoot post. this allows the hindfoot to evert (or 'pronate', if you must). the arch must be kept low for this to work. since it doesn't have to match the high arch it can be made OTC. djOrtho should have it available within a couple of months.

brian graham, cped,has been making these for us for the last 5+ years. but, if you don't have anyone who can make them in your area, this should be a useful device. our biggest problem has been to educate people in how to find the subtle cavus foot and how to do the block test.

almost everyone we see who is an athlete, has been reflexly told they are 'pronators.' when you point out that they are not, they think you are CRAZY. the population studies that are coming out of seattle and montana show that apx. 25% of all people may have subtle cavus.

this material is being published this month, March, 2005, in Foot & Ankle International. Brian Graham, C.Ped is co-author.



Re: For Richard Question re: arch supports

elliott on 3/06/05 at 04:01 (170557)

Dr. Manoli:

Thanks for your comments. I understand from the literature and the opinions I received that there can be many different surgical approaches to PTTD stage 2 accomplishing the same thing. What made my case even more difficult is that while I had adult acquired flatfoot, I did not have any obvious PTTD. I have always felt that the very tight post-op cast from a previous surgery may have raised that first ray and left me with the instability I didn't have before that surgery, but I don't think any of the docs believed me.

Regarding a lateral column lengthening, I did not have this done. The first opinion was for it, but the rest warned not to, with some claiming it is in general not tolerated well, at least by adults.

The opening wedge medial cuneiform osteotomy did leave me with a nice-looking arch. I'm still not even at the weightbearing phase yet, so I'll reserve opinion as to how effective the procedure was until much later. Thanks for your reply.