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1.
ACHILLES TENDONITIS
Characterized by
inflammation due to micro tears within the tendon
or inflammation of the subcutaneous and subtendinous
bursae. The condition is aggravated by tension
on the tendon due to equinus conditions, stretching
the tendon too early in the therapeutic process,
impact activity that involves forcing the foot
into dorsiflexion
Footwear
Considerations:
• Firm, snug-fitting and deep heel counter
in the shoe
• Internal (up to 6mm if no heel lifts are
added on to the orthotics) and/or external heel
lifts made from an incompressible material
• Shoe laces to be tightly secured (diabetics
excluded)
Orthotic Considerations
Strongly
Recommended:
• Order as
high an arch profile as the patient will be able
to tolerate (depending on the patient’s
non- weightbearing arch height, degree of arch
collapse on weightbearing, their age, activity
level, level of tolerance to changes, etc.)
• Incorporate 3mm to 6mm heel lifts (these
should be reduced in height once the condition
has improved, again making sure the heel counter
of the shoe can accommodate the increased height
without the patient’s heel slipping during
walking)
Optional:
• Incorporate
2mm medial heel skives if the patient shoes excessive
calcaneal eversion on weightbearing
• Incorporate plantar fascial grooves (mark
these on the patient’s foot with lipstick
before making the impression), if the patient
presents with a prominent medial slip of the plantar
fascia on dorsiflexion of the hallux
• Incorporate a deep heel cup if excessive
calcaneal eversion is noted on weightbearing.
(The heel cup depth should be greater than 14mm
and up to 20mm, making sure that the heel counter
of the shoe will allow the increased width that
accompanies a deeper heel cup)
• Incorporate Morton’s Extensions
if the patient presents with short 1st metatarsals
• Incorporate soft medial flanges in cases
of extreme navicular drop on weigthtbearing, (making
sure that the shoe can accommodate the increased
width associated with this addition)
2.
CALLUSES
Calluses
develop because of excessive pressure in a specific
area of the foot. The intermittent “on-off”
pressure during gait causes the capillaries feeding
the germinal cells of the epidermis to become
“leaky.” This increases epidermal
cell growth in the region. The same pressure also
prohibits desquamation of the outermost layer
of the epidermis leading to impacting, and over
time, to the formation of keratin.
Footwear
Considerations:
• Firm,
snug-fitting and deep heel counter in the shoe
• Shoe laces to be tightly secured (diabetics
excluded)
Orthotic Considerations
Strongly Recommended:
•
Pronation Related: Order as high an arch profile
as the patient will be able to tolerate (depending
on the patient’s non- weightbearing arch
height, degree of arch collapse on weightbearing,
their age, activity level, level of tolerance
to changes, etc.)
• Supinated Foot Type Related: Ask for 25%-50%
cast dressing on the plaster positive cast
• Incorporate metatarsal pads to create
a transverse arch support in the forefoot which
serves to offload the metatarsal heads
• Specify additional cushioning in the forefoot
to reduce shock related pain
• Ask the lab to create depressions in the
top cover to offload severe callus. This should
be done after accurate marking in the negative
impression
Optional:
• Incorporate
3mm heel lifts if a muscular equinus condition
exists
• Incorporate 2mm medial heel skives if
the patient shoes excessive calcaneal eversion
on weightbearing
• Incorporate plantar fascial grooves (mark
these on the patient’s foot with lipstick
before making the impression), if the patient
presents with a prominent medial slip of the plantar
fascia on dorsiflexion of the hallux
• Incorporate a deep heel cup if excessive
calcaneal eversion is noted on weightbearing.
(The heel cup depth should be greater than 14mm
and up to 20mm, making sure that the heel counter
of the shoe will allow the increased width that
accompanies a deeper heel cup)
• Incorporate Morton’s Extensions
if the patient presents with short 1st metatarsals
• Incorporate soft medial flanges in cases
of extreme navicular drop on weigthtbearing, (making
sure that the shoe can accommodate the increased
width associated with this addition)
3.
MORTON'S NEUROMA
This
pathology is caused by the impingement of two
adjacent metatarsal heads on the proper digital
branches of the medial plantar nerve. The constant
shearing of the adjacent metatarsal heads “thickens”
the nerve sheath in the region. The most common
site for a Morton’s Neuroma is in between
the 3rd and 4th metatarsal heads where the medial
and lateral columns of the foot meet. The etiology
is one of abnormal subtalar joint pronation, which
leads to this shearing action during each step
of the gait cycle. Narrow shoes that squeeze the
metatarsal heads together further exacerbate this
condition
Conservative management (short of surgery) strives
to limit the abnormal pronation (and thus the
shearing action between the metatarsal heads and
to separate the metatarsal heads so as to relieve
the lateral pressure on the nerve
Footwear
Considerations:
• Firm, snug-fitting
and deep heel counter in the shoe
• Shoe laces to be tightly secured (diabetics
excluded)
• Wide toe box in the shoe to eliminate
the squeezing action on the metatarsal heads
Orthotic Considerations
Strongly Recommended:
• Order as
high an arch profile as the patient will be able
to tolerate (depending on the patient’s
non- weightbearing arch height, degree of arch
collapse on weightbearing, their age, activity
level, level of tolerance to changes, etc.)
• Either incorporate metatarsal pads to
create a transverse arch support in the forefoot
which serves to separate the metatarsal heads
or use a neuroma pad (a thin wedge shaped pad)
placed on the upper surface of the orthotic (between
the adjacent metatarsal heads at the site of the
neuroma) to create the separation
Optional:
• Incorporate
3mm heel lifts if a muscular equinus condition
exists
• Incorporate 2mm medial heel skives if
the patient shoes excessive calcaneal eversion
on weightbearing
• Incorporate plantar fascial grooves (mark
these on the patient’s foot with lipstick
before making the impression), if the patient
presents with a prominent medial slip of the plantar
fascia on dorsiflexion of the hallux
• Incorporate a deep heel cup if excessive
calcaneal eversion is noted on weightbearing.
(The heel cup depth should be greater than 14mm
and up to 20mm, making sure that the heel counter
of the shoe will allow the increased width that
accompanies a deeper heel cup)
• Incorporate Morton’s Extensions
if the patient presents with short 1st metatarsals
• Incorporate soft medial flanges in cases
of extreme navicular drop on weigthtbearing, (making
sure that the shoe can accommodate the increased
width associated with this addition)
4.
CLAW TOES
A claw toe is a toe that is contracted at the
PIP and DIP joints (middle and end joints in the
toe), and can lead to severe pressure and pain.
The etiology usually involves long standing digital
retraction due to extensor over pull. Claw toes
may occur in any digit, except the hallux. There
is often discomfort at the top part of the toe
that is rubbing against the shoe and at the end
of the toe that is pressed against the bottom
of the shoe.
Claw toes are classified based on the mobility
of the toe joints. There are two types - flexible
and rigid. In a flexible claw toe, the joint has
the ability to move. This type of claw toe can
be straightened manually.
A rigid claw toe does not have that same ability
to move. Movement is very limited and can be extremely
painful. This sometimes causes foot movement to
become restricted leading to extra stress at the
“ball” of the foot, and possibly causing
pain and the development of corns and calluses.
Footwear
Considerations:
•
Deep, wide toe-box to accommodate the deformity
• Firm, snug-fitting and deep heel counter
in the shoe
• Shoe laces to be tightly secured (diabetics
excluded)
Orthotic
Considerations
Strongly
Recommended:
• Order as high an arch profile
as the patient will be able to tolerate (depending
on the patient’s non- weightbearing arch
height, degree of arch collapse on weightbearing,
their age, activity level, level of tolerance
to changes, etc.)
• Incorporate metatarsal pads to create
a transverse arch support in the forefoot, which
serves to offload the metatarsal heads. When upward
pressure is applied to the proximal metatarsal
heads, the digits extend horizontally (flexible
claw toes only) forward preventing the clawing
to become long standing and therefore rigid
• Specify additional cushioning in the forefoot
to reduce shock related pain
• The use of external toe props to offload
the apices of the digits
Optional:
•
Incorporate 3mm heel lifts if a muscular equinus
condition exists
• Incorporate 2mm medial heel skives if
the patient shoes excessive calcaneal eversion
on weightbearing
• Incorporate plantar fascial grooves (mark
these on the patient’s foot with lipstick
before making the impression), if the patient
presents with a prominent medial slip of the plantar
fascia on dorsiflexion of the hallux
• Incorporate a deep heel cup if excessive
calcaneal eversion is noted on weightbearing.
(The heel cup depth should be greater than 14mm
and up to 20mm, making sure that the heel counter
of the shoe will allow the increased width that
accompanies a deeper heel cup)
• Incorporate Morton’s Extensions
if the patient presents with short 1st metatarsals
• Incorporate soft medial flanges in cases
of extreme navicular drop on weigthtbearing, (making
sure that the shoe can accommodate the increased
width associated with this addition)
5.
METATARSALGIA
Characterized
by pain in the “ball” of the foot,
metatarsalgia is due to a variety of etiologies:
plantarflexed metatarsals due to extensor over-pull
accompanied by digital retraction; hypermobility
of the 1st ray due to peroneus longus weakness
allowing the bulk of the plantar load to fall
on the 2nd to 4th metatarsal heads; distal shifting/atrophy
of the fibro-fatty pad under the metatarsal heads
due to digital retraction or advanced age respectively.
Shoes without cushioning in the forefoot exacerbate
this condition
Footwear
Considerations:
•
Firm, snug-fitting and deep heel counter in the
shoe
• Shoe laces to be tightly secured (diabetics
excluded)
Orthotic Considerations
Strongly
Recommended:
•
Order as high an arch profile as the patient will
be able to tolerate (depending on the patient’s
non- weightbearing arch height, degree of arch
collapse on weightbearing, their age, activity
level, level of tolerance to changes, etc.)
• Incorporate metatarsal pads to create
a transverse arch support in the forefoot which
serves to offload the metatarsal heads
• Specify additional cushioning in the forefoot
to reduce shock related pain
Optional:
•
Incorporate 3mm heel lifts if a muscular equinus
condition exists
• Incorporate 2mm medial heel skives if
the patient shoes excessive calcaneal eversion
on weightbearing
• Incorporate plantar fascial grooves (mark
these on the patient’s foot with lipstick
before making the impression), if the patient
presents with a prominent medial slip of the plantar
fascia on dorsiflexion of the hallux
• Incorporate a deep heel cup if excessive
calcaneal eversion is noted on weightbearing.
(The heel cup depth should be greater than 14mm
and up to 20mm, making sure that the heel counter
of the shoe will allow the increased width that
accompanies a deeper heel cup)
• Incorporate Morton’s Extensions
if the patient presents with short 1st metatarsals
• Incorporate soft medial flanges in cases
of extreme navicular drop on weigthtbearing, (making
sure that the shoe can accommodate the increased
width associated with this addition)
6.
PLANTAR FASCIITIS HEEL PAIN
Typically
caused by micro tears at the periosteal attachment
of the medial slip of the plantar fascia at the
medial calcaneal tubercle, leading to inflammation
and pressure on the medial calcaneal branch of
the tibial nerve. Symptoms may exist whether or
not a heel spur is seen on radiological examination
Footwear
Considerations:
•
Firm, snug-fitting and deep heel counter in the
shoe
• Shoe laces to be tightly secured (diabetics
excluded)
Orthotic Considerations
Strongly Recommended:
• Order as high an arch profile
as the patient will be able to tolerate (depending
on the patient’s non- weightbearing arch
height, degree of arch collapse on weightbearing,
their age, activity level, level of tolerance
to changes, etc.)
• Incorporate 3mm heel lifts (making sure
the heel counter of the shoe can accommodate the
increased height without the patient’s heel
slipping during walking)
Optional:
•
Incorporate 2mm medial heel skives if the patient
shoes excessive calcaneal eversion on weightbearing
• Incorporate plantar fascial grooves (mark
these on the patient’s foot with lipstick
before making the impression), if the patient
presents with a prominent medial slip of the plantar
fascia on dorsiflexion of the hallux
• Incorporate a deep heel cup if excessive
calcaneal eversion is noted on weightbearing.
(The heel cup depth should be greater than 14mm
and up to 20mm, making sure that the heel counter
of the shoe will allow the increased width that
accompanies a deeper heel cup)
• Incorporate Morton’s Extensions
if the patient presents with short 1st metatarsals
• Incorporate soft medial flanges in cases
of extreme navicular drop on weigthtbearing (making
sure that the shoe can accommodate the increased
width associated with this addition)
7.
BUNIONS
This
pathology known completely as “Hallux Abductovalgus”
is identified by the following:
1. A medio-dorsal osteophyte in the 1st metatarsophalangeal
joint
2. Abduction of the hallux towards the second
digit
3. Valgus rotation of the hallux
The bunion deformity is caused by two
prevalent factors must occur together for the
condition to initiate and progress:
1. A genetic predisposition towards an adductus
foot type, and
2. Abnormal subtalar joint pronation
Since the genetic predisposition is unalterable,
the practitioner strives to manage the abnormal
pronation in order to arrest the progression of
the deformity. Arresting the abnormal pronation
is a major factor in preventing the progression
of the deformity but cannot reverse the deformity
short of surgery
Footwear
Considerations:
• Firm, snug-fitting
and deep heel counter in the shoe
• Shoe laces to be tightly secured (diabetics
excluded)
• Wide and deep toe box in the shoe to accommodate
the deformity and possible digital deformities
caused by the over/under riding of the hallux
with respect to the second digit
Orthotic Considerations
Strongly Recommended:
• Order as
high an arch profile as the patient will be able
to tolerate (depending on the patient’s
non- weightbearing arch height, degree of arch
collapse on weightbearing, their age, activity
level, level of tolerance to changes, etc.)
• Incorporate metatarsal pads to create
a transverse arch support in the forefoot which
serves to offload the metatarsal heads
• Specify additional cushioning in the forefoot
to reduce shock related pain
Optional:
• Incorporate
3mm heel lifts if a muscular equinus condition
exists
• Incorporate 2mm medial heel skives if
the patient shoes excessive calcaneal eversion
on weightbearing
• Incorporate plantar fascial grooves (mark
these on the patient’s foot with lipstick
before making the impression), if the patient
presents with a prominent medial slip of the plantar
fascia on dorsiflexion of the hallux
• Incorporate a deep heel cup if excessive
calcaneal eversion is noted on weightbearing.
(The heel cup depth should be greater than 14mm
and up to 20mm, making sure that the heel counter
of the shoe will allow the increased width that
accompanies a deeper heel cup)
• Incorporate Morton’s Extensions
if the patient presents with short 1st metatarsals
• Incorporate soft medial flanges in cases
of extreme navicular drop on weigthtbearing, (making
sure that the shoe can accommodate the increased
width associated with this addition)
8.
SHIN SPLINTS
Two
presentations exist, either together or independent
of each other:
1. Tibialis
Anterior Shin Splints: Characterized by pain in
the shins (anterior part of the tibia) during
fast walking, running or maintaining paces on
a treadmill. Abnormal pronation causes the subtalar
joint axis to be displaced medially thus bringing
it in line with the tibialis anterior tendon.
As the muscle fires to clear the swing leg from
the ground, it therefore has a minimal effect
in supinating the subtalar joint and leads to
micro tears in its periosteal attachment along
the tibia followed by pain and inflammation in
the region.
2. Tibialis
Posterior Shin Splints: Characterized by pain
in the anterior medial region of the lower leg,
along the origins of the tibialis posterior muscle
with the interosseous membrane between the tibia
and fibula. Pain can be elicited during examination
by deep palpation of the region. Abnormal pronation
causes the tibialis posterior muscle to be ineffective
during firing in re-supinating the subtalar joint,
leading to tibialis posterior shin splints where
micro tears in its periosteal attachment along
its origins leads to pain and inflammation in
the region
Of the two pathologies,
Tibialis Anterior Shin Splints are easier to manage
than Tibialis Posterior Shin Splints. For the
posterior shin splints, maximal control against
abnormal pronation is warranted, using ALL the
control features outlined below. For the anterior
shin splints, a moderate degree of control is
sufficient and the severity of controls listed
below may be reduced
Footwear
Considerations:
•
Firm, snug-fitting and deep heel counter in the
shoe
• Shoe laces to be tightly secured (diabetics
excluded)
Orthotic Considerations
Strongly Recommended:
• For the
posterior shin splint condition, order as high
an arch profile as the patient will be able to
tolerate (depending on the patient’s non-
weightbearing arch height, degree of arch collapse
on weightbearing, their age, activity level, level
of tolerance to changes, etc.) A moderate arch
profile may suffice to treat anterior shin splints
• Incorporate soft medial flanges in cases
of extreme navicular drop on weigthtbearing, together
with additional arch pads in case of severe pes
planus (making sure that the shoe can accommodate
the increased width associated with this addition)
Optional:
• Incorporate
3mm heel lifts if a muscular equinus condition
exists
• Incorporate 2mm medial heel skives if
the patient shoes excessive calcaneal eversion
on weightbearing
• Incorporate plantar fascial grooves (mark
these on the patient’s foot with lipstick
before making the impression), if the patient
presents with a prominent medial slip of the plantar
fascia on dorsiflexion of the hallux
• Incorporate a deep heel cup if excessive
calcaneal eversion is noted on weightbearing.
(The heel cup depth should be greater than 14mm
and up to 20mm, making sure that the heel counter
of the shoe will allow the increased width that
accompanies a deeper heel cup)
• Incorporate Morton’s Extensions
if the patient presents with short 1st metatarsals
9.
PATELLOFEMORAL DYSFUNCTION
Two
presentations exist, either together or independent
of each other:
The common etiology of Patellofemoral Dysfunction
is excessive tibial internal rotation which accompanies
abnormal subtalar pronation. In addition to navicular
drop (arch collapse) and calcaneal eversion, the
tibia with its patella tendon attachment on the
tibial tuberosity rotates internally excessively.
This causes the patella to maltrack in the anterior
femoral condoyls, ineffectiveness in the vastus
medialis obliqus muscle fibres and an overpull
of the vastus lateralis muscle leading to pain
usually found in the lateral knee. The purpose
of orthotic therapy is to limit the amount of
tibial internal rotation by limiting the amount
of pronation in the subtalar joint. The practitioner
should be cautioned, however, that too much control
in the orthotic device may lead to other painful
symptoms in the knee joint, and the amount of
control (especially in the height of the arch
profile of the orthotic) should be monitored carefully.
If in doubt, order the device with a moderate
arch profile, and after monitoring the patient’s
symptoms after intervention, this can be increased
by external additions to the device.
Footwear
Considerations:
• Firm, snug-fitting and deep heel counter
in the shoe
• Shoe laces to be tightly secured (diabetics
excluded)
Orthotic
Considerations
Strongly Recommended:
• Order a
medium arch profile, which can be increased externally
if nescessary (depending on the patient’s
non- weightbearing arch height, degree of arch
collapse on weightbearing, their age, activity
level, level of tolerance to changes, etc.)
Optional:
• Incorporate
3mm heel lifts if a muscular equinus condition
exists
• Incorporate 2mm medial heel skives if
the patient shoes excessive calcaneal eversion
on weightbearing
• Incorporate plantar fascial grooves (mark
these on the patient’s foot with lipstick
before making the impression), if the patient
presents with a prominent medial slip of the plantar
fascia on dorsiflexion of the hallux
• Incorporate a deep heel cup if excessive
calcaneal eversion is noted on weightbearing.
(The heel cup depth should be greater than 14mm
and up to 20mm, making sure that the heel counter
of the shoe will allow the increased width that
accompanies a deeper heel cup)
• Incorporate Morton’s Extensions
if the patient presents with short 1st metatarsals
• Incorporate soft medial flanges in cases
of extreme navicular drop on weigthtbearing, (making
sure that the shoe can accommodate the increased
width associated with this addition)
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