Clinical Biomechanics for Podiatry: Adding More Stability to non-posted Orthotic Devices

The 2 pairs of orthotic devices above are actually the same pair. The patient Luz presented to my office with the pair in the top photo of prescription orthotic devices. These orthotic devices were not controlling her pronation motion enough, and I felt that some of her symptoms could be caused by this motion. Instead of just making a new pair, I was able to get more stability by teaching her power lacing, and having the podiatry laboratory place extrinsic rearfoot posts (brown) and arch reinforcements (white). This simple solution can be the subtle difference in motion that eliminates pain. This is one example of the art of medicine combined with the KISS principle that I use on a routine basis with great results for patients. 

     This technique was taught to me by the famous Dr Christopher Smith, our biomechanics clinic head at school, and owner of Northwest Podiatric Orthotic Laboratory in Blaine, Washington. When you add a stable shoe, if the patient was not originally wearing, miracles can happen in stability and comfort. 

Clinical Biomechanics for Podiatry (Post #2): Foot Orthotic Devices: General Principles

There are many types of foot orthotic devices for the consumer. They fall into 5 categories based on the needs of the patient. These 5 categories are:

1. Corrective (or Controlling)
2. Stabilizing (or Balancing)
3. Shock Absorbing (or Cushioning)
4. Accommodative (or Weight Transferring)
5. Combination (or Multi-Functional)

How is the correct orthotic device ordered or purchased? The orthotic device that you prescribe, or that you recommend purchasing in a store, may or may not help if it is not the correct type. At its best, the correct orthotic device will successfully make the necessary change in mechanics, but it may still be crucial to work on all the other aspects of rehabilitation (anti-inflammatory, flexibility, strengthening, etc.) in order to relieve all your symptoms. It is important when prescribing the orthotic device that you are familiar with the many different types of orthotic devices available. It is also important for the patient/customer to be somewhat clear on what type of orthotic device is needed. And, unfortunately, the type of orthotic device required today may change in the future with different sports, different symptoms, different shoe types, and different age. You need to be willing to change to a different type of orthotic device if the patient's symptoms are not improving with the present pair of orthotics, and if there is another type available that may help them. Sometimes, practitioners don’t like discussing this type of change due to the added cost to the patient, but it is important that they know there are options.

Corrective or Controlling Orthotic Devices do what they say---correct or control excessive pronation or supination (the inward collapse of the arch, or the outside roll of the ankle, respectively). This type of orthotic device produces the most dramatic change in function, and may take the most time to get used to wearing.

Stabilizing or Balancing Orthotic Devices normally do not change foot position much, but the patient/customer feels more centered, more balanced. The weight of any point can become so distributed that only a small fraction of the original weight bearing still exists. This can be vital for heel pain, some arch pain, fifth metatarsal base pain, and many metatarsal problems.

Shock Absorbing or Cushioning Orthotic Devices take the stress out of the pounding of heel impact. Runner’s versions need to have equal cushion at the heel and forefoot. These can dramatically reduce the stresses which cause or aggravate stress fractures, joint pains (knee and hip), and heel pain. One of the best shock absorbing orthotic devices is the Hannaford which will be discussed later.

Accommodative or Weight Transferring Orthotic Devices try to transfer weight from a painful area to a non-painful area. These orthotic devices have probably been around the longest of all orthotic devices prescribed by podiatrists. If you have heel pain, you need an orthotic device that transfers weight into the arch. If you have sesamoid pain, you need an orthotic to transfer weight back into the arch and onto the 2nd and 3rd metatarsal heads.

Combination or Multi-Functional Orthotic Devices are probably the most prescribed type of orthotic device. The prescribing practitioner attempts to accomplish multiple tasks with one type of orthotic device. This is why there are so many types of orthotic devices out there. When you really study them, most primarily do one of the 4 basic functions really well, and then 1 to 3 of the other functions somewhat or not at all. A good practitioner will try to get the most out of orthotic therapy. This means that the practitioner tries to combine different functions into each orthotic device on a routine basis. Sometimes, however, doing too much sacrificing the most important function.

Hopefully, this post helped you understand some of the basics of orthotic therapy. When discussing with a patient, try to understand what we want the orthotic device to do. Ask yourself these questions:

1. Do I need to order a corrective device to change foot positioning?
2. Does the patient primarily need to feel more centered and stable?
3. Do they need cushion/shock absorption as they walk or run?
4. Do they need to transfer weight from a painful area to a non-painful area?
5. Do they need a multi-purpose orthotic device with many functions to help the problems at hand?

Perhaps the patient will need several orthotic versions since their activities, shoe gear, etc. vary so much. The doctor and patient must be on the same relative page, and the patient must be aware that there may be a plan B. 

Orthotic Arch Height

Dr Huppin discusses a simple, but very important, concept in arch height. I am amazed at how many times I find not correction in this area. However, it is not that simple, since many corrections for supination tend to correct laterally (outside of the foot) and not medially. You should never feel that the shoe and ortho combination makes you unstable to the outside. If your dealing with metatarsal or heel pain, you desperately need weight transfer to the arch. Very crucial say with plantar fasciitis or sesamoid injuries. 

http://www.podiatrytoday.com/blogged/key-pointers-increasing-orthotic-arch-height

Foot Stability with Extrinsic Rearfoot Posts: Sexy Title!!

If any of you have orthotic devices, I invite you to comment on them. What they have done for you, what problems you have had? I repeatedly, since I am getting older, have patients express distress that I may retire someday and they will not be able to get good orthotics. I am honored, but it points to how important they are to so many people. I have been given quite a gift in life to be able to help these patients. For that, I am forever grateful to my profession and my mentors. 

     This short video goes over a small, but very powerful, part of the orthotic device called the rearfoot post. I owe Dr Christopher Smith, founder of SuperFeet, and one of my kind mentors, for introducing me to birkocork. Prior to birkocork, the posts I made were very hard. Birkocork posts are so much kinder on the knee and hip joints due to their shock absorption. 

https://youtu.be/7SjkTwynaQM

When to Use Foot Orthotic Devices

Hi Dr Blake,

I just wanted to get your thoughts on the question that I have which is some patients will ask me "Do I have to wear orthotics / or a heel lift for the rest of my life?''

I generally respond with

- it depends on the severity of the condition

- as the stress on the injured tissue is reduced which allows the tissue to heal and adapt to its optimal function over a period of time,

I can gradually reduce the correction of the orthotics and incorporate corrective exercises to see if the patient is able to adapt without orthotics.

If symptoms reappear when the orthotics is removed after the patient is asymptomatic, then I will explain that the patient will need to continue wearing orthotics.

Looking forward to your response.

Regards,

Dr Blake's response: 

     Most definitely. I explain that orthotics, like glasses, are necessary evils to be used as needed. For some injuries like sesamoid fractures, it can be easy two years of mandatory use, and other injuries like plantar fasciitis, only two months longer than the symptoms. That is the injury protection part. Now, when we are evaluating patients, some patients get the same problem over and over, so long term use of orthotic devices for activities that produce those symptoms are important. But, they may only wear them to run twice weekly, or if they have a big backpacking trip coming soon. 

     And then there are the patients who have very severe biomechanical problems that should always wear their orthotics if the orthotic devices can correct that problem. These are patients with severe pronation, PTTD, lateral instability with chronic sprains, etc.

     A subcategory of this are the preventative patients. Patients that wear orthotics to slow down the course of their bunions, forefoot neuritis, heel pain, achilles symptoms, knee degeneration, frequent ankle sprains, etc. They probably could get by without orthotic devices alot, but chose to use them AMAP. 

     And you bring up a great point about exercises. If you are using orthotic devices to reduce the effects of pronation or supination, you should place that patient on exercises done 3 times weekly to do the same thing. As they get stronger, than they can go longer without orthotic devices, and perhaps not have to use them at all.  Hope this helps. Rich

Orthotic Challenges: Coming to San Francisco?

Hi - I am a huge fan and I follow your blog consistently. You continue to inform me and I thank you for taking time to educate us all.

I live in Los Angeles, and I am thinking of making an appointment for you to make me some orthotics.  I haven't had much luck with that down here.

My problem is I have high arches, pronate, bad FAT PAD ATROPHY, and a case of plantar fasciitis.Oh, and did I mention a neuroma...? I also have very flexible feet and ankles. (hyper-mobile) I guess I am a worse case scenario for fitting orthotics? I have had several unsuccessful attempts over the last couple of years and my life does include coping with pretty bad pain on a daily basis.  I guess I need orthotics with 'structure' yet softness and that seems to be the major hurdle.
Would you be willing to give it a whirl? If so - - how do I proceed?
I read in one post you asked a patient from Los Angeles to come up for a Friday appointment and then return for the fitting Monday?Did I read that correctly? Please advise.... and THANK YOU in advance!!!  : )
Mary (name Changed)

Dr Blake's response: 

Dear Mary, 

    I love these challenges and we can arrange a Friday appt and then a Mon morning appt to fly back. I need the weekend to complete the orthotic process, and because of my own personal schedule, I need to make sure it is a weekend I am around. It is best to email me or leave a voicemail message at 415-353-6417 and I will try to arrange things. Please give me 2 or 3 weekends that will work and I will choose the best one. I am at 900 Hyde Street in San Francisco, so you can google it. Typically, I will make one or two types of corrections (some corrections are better for one thing and not the other, or so so with the other. With all the problems, some super duper Hybrid orthotic device will be in order. I hope we can meet and get this one. If you can emotionally plan on doing the same thing one month later, we can perfect the learning process begun on the first weekend. Thanks for the compliments Rich

Orthotics causing Back Pain: A Common Problem with various Solutions

Dr. Blake,

I had posted about sesamoid problem after bunion surgery, and thank you so much for answering my questions.

I am on second pair of custom orthotics and my back was so irritated that I could not function, missed one week of work, could not even stand long enough to make a meal.  I had times that my right side foot and leg just wanted to give up. Went to see a podiatrist hoping for help, he took the time to look at my x-ray before and after surgery, and told me the surgery was well done, except the first metatarsal bone was longer than it's supposed to be, which caused all my other problems.  He said surgery should be the last option, instead we should try pads.

Dr Blake's comment: Functional Foot Orthotics are just that----functional. They make a functional change in your body, and as podiatrists, we ask the rest of the body to please accept the change. When designing orthotic devices for sesamoid pain, two common problems can occur leading to back pain. The orthotic device places your weight too lateral, making you over supinate, leading to back pain. If this is the case, you should feel that the weight is going to your baby toe as you walk through your foot, or even worse, feel like you can sprain your ankle. Typically, the orthotic devices make you straighten your knee too much, and if you have tight hamstrings, the pull on the low back causes pain. These are easy things to change if recognized. Sometimes a simple adjustment can be made to allow you to be more centered or slightly more pronated. It is up to the prescribing provider to recognize what is going on when they watch you walk. Sometimes a whole new orthotic device is necessary. But, it is important to know what most likely caused the problem in the first place, so that you do not repeat the same mistake. 

This is what I felt ever after the surgery but you cannot do much to change the fact and it is affecting so much of my life now, I am horrified to think about another surgery, but other options seem to be running out.
Dr Blake's comment: If the metatarsal is too long, and it is causing all these problems, a temporary fix with orthotics should be able to be made. A long first metatarsal does potentially 3 bad things: supinates you too much (that can be corrected with orthotics), blocks your ability to roll properly through your foot jerking your low back (that can be corrected with orthotics), and straightens your knee too much by limiting normal arch pronation (that can be corrected with an orthotic device). I would always recommend trying to accomplish an orthotic fix for the problem first to make sure everyone truly understands the source of the problem. Then, if surgery makes sense, go for it. 

Your blog taught me more than all of the orthopedics surgeons told me, I really don't know what to do next, my big toe and the rest of four other toes simply don't land on the same level, and I felt the function of nerves and muscles are all affected.

I will seek other doctor's opinions locally, but I am so concerned about loosing foot and leg functions. Do you think correcting the bone(surgery) would help with sesamoid issue long term, or is it even possible to have surgery with sesamoid issue present?
Dr Blake's comment: You need information based on function not x rays right now. Go to a good sports medicine physical therapy that watches you walk. Do not influence them by previous conceived notions. Let me try and tie together your gait and back pain. I am assuming that the orthotic devices corrected for the sesamoid but lead to the back pain. Right? This is so common, I can not tell u!!! But, it may be an easy orthotic fix. Keep me in the loop. 

Thank you so much for your time, and how I wish I lived in California!

Further response from patient:

Thank you so much Dr. Blake!

I had one Acupuncture Dr. and one Orthopedics Dr. both suggested simply try Dr. Schol's full-length gel pad, which I did, I cut out some felt pads according to your website instruction, simply trying to level other four toes with the big toe, and a cutout to accommodate the sesamoid area. So far, have not had any bad pain yet.

I so appreciate your time.

Research on Treatments can be very difficult: Take Foot Orthotic Devices For Example

     I received this email from a patient who is getting good help of his posterior tibial tendinitis secondary to over pronation from his orthotic devices. Due to the asymmetry of his pronation, his left orthotic device is much higher corrected than his right. This is what he needed to be stable.He is an extremely brilliant young man, and wants to know how things work and what works. Research on most products, like this article on orthotic devices, which have helped billions of people, is very difficult. Our medical directior, famous orthopedist Dr James Garrick, who loves his patients to stretch has always been frustrated at the fact that no research (only public opinion) has ever proved that stretching does anything. I know it does, you probably know it does, but put it under a microscope, exam it, probe and poke at it, and you will find it very hard to document scientifically how it works. Finally, after 50 plus years of the western medical world taking a negative stand on acupuncture for instance, now research is showing some of the reasons why it works so well.
     Foot orthotic devices are another one scrutinized. Most of the one billion people who wear and swear by their foot orthotics, and would not dream about doing at least some part of their daily life without them, would tell you have great they are. So why do famous orthotic researchers say to throw away your orthotic devices. I have reviewed some of the orthotic research and find many flaws in almost everyone of the papers. Orthotic devices are medical devices that must be individualized before they can really work. The research projects tend to miss the boat on this. As I review these papers I try to understand how the orthotic devices were made and the research flaws become apparent. Here are some of the questions I ask that point to the study's flaws. What type of orthotic was made? How individualized the orthotic RX was? What types of shoes and lacing techniques were they wearing? How long were they wearing the study orthotics, and had they been adjusted to the wear individuallly? Had the researcher documented that the orthotic devices completely eliminated the abnormal motion that was being studied? How many hours on the treadmill had the runner/walker done before being videotaped for the study? Were the orthotics coupled with good shoes, power lacing, and other typical day to day things that even the average orthotic prescriber would do? And on, and on, and on!! As you read the research, and you look at the lack of sophisication, it is typically on the guise of standardization. The researcher wants to only study the orthotics, so standardizes the prescription, shoes, surface, etc. But, this truly means that the researcher is really studying a generic device, not a custom made functional foot orthotic.
     When I prescribe orthotic devices, it is important that the left and right feet get different corrections when they need them, that the patient get shoes that stabilize them very well, that they power lace, that they wear lifts for their short side if it affects their gait, that they strengthen or stretch muscles that adversely effect how their bodies move, that they learn better running or walking styles when their gait is affected. All of this aims for stability and less shock to the body. So, when I see a great research paper that addresses this individualization of the process within the study, then I will look with more seriousness at the paper, and then the best research paper on custom made functional foot orthotics will have been written.


http://www.nytimes.com/2011/01/18/health/nutrition/18best.html?pagewanted=all&_r=0

 Dr. Blake, Thank you for my new orthotics. Again, it was good to see you and talk with you. Above is a link to the NY Times article I mentioned. Look at the January '11 date, its surprising its been that long since I read it. I'd be curious to hear what you think the next time I'm in your offices. Happy holidays and happy new year!

Extrinsic Rearfoot Posting: Adding Stability with Birkocork

The following photos demonstrate the application of an extrinsic rear foot post. For many custom made orthotics, they are a vital component. For many Over The Counter devices like Superfeet, they can be added for greater stability. The Birkocork material is the same material used in Birkenstock sandals. It is heat moldable, and easily sanded. The material I purchase from JMS Plastics in New Jersey is bought 10mm thickness hard. It is heated in a convention oven at 475 deg F for 5 plus minutes until browning on top. 

Typical San Francisco Sunrise!!

Extrinsic Rearfoot Post after years of wear and no longer stable against the ground. The entire post should be on the ground flush for maximal stability.

Another view of how the worn down rear foot post is no longer stable and in full contact with the ground.

The original post is removed. The surface is glued with Barge cement as is the surface of the birkocork. It is let to dry for 10 minutes.

Then the birkocork is heated at 475 deg F for 5 plus minutes until the top starts to brown.

It is now laid on top of the heel area of the orthotic device.

Utilizing a glued hand, the birkocork is molded to the shape of the heel cup.

Then the birkocork is placed on the ground and the sides are pushed in to attempt a straight vertical wall around the heel cup. All excess will be ground later by a sander.

This demonstrates 2 rear posts with birkocork, one in its raw stage, and the other sanded. The bottom surface needs still to be sanded.

This demonstrates the complete extrinsic rear foot post ground to be in full contact with the supporting surface at the same time that the leading edge of the orthotic is in full contact with the ground.

Another view of the rear foot post flush with the ground as is the front or leading edge of the orthotic device. This is very stable. 

Another view of the complete sanded extrinsic rear foot post and a raw, not yet sanded, birkocork heel. 

How to Add More Stability to An Orthotic Device Via Topcovers

This simple trick has made many orthotic devices more stable over the years. Here I show a more complex version, but the general principle can be used just by adding a new top cover with medial and lateral wings. When the patient places their foot in the shoe, they must make sure the wings do not end up under their foot. They should be between your foot and the shoe. This trick can also be used with power lacing and simple tongue pads to greatly stabilize the foot and ankle for less pronation/supination tendencies. 

Here is a right orthotic device that I will add stability to by using 1/8th inch poron (JMS Plastics) to the medial and lateral sides of the heel cup area. This will increase the surface area to grab the foot from moving. Of course, for a severe supinator, this can be done only to the lateral side (baby toe side), and for a severe pronator, this can be done only on the medial side (arch side).

Here the poron has been glued and the poron has been skived along the edge of the plastic. 

The poron is now rounded to mold to the shoe easier.

Leather is used to reinforce the outside of the flaps or wings as I like to call them to make it more sturdy.

Here the leather reinforcement has been glued.

Here you can see the leather goes all the way down to the bottom of the rear foot extrinsic post.

Here the leather has been trimmed.

Side view of the wings created by the poron and leather. Any shoe repair store will have some scrapes of leather to use.

Another view on how the poron has been skived or beveled.

Here 1/8th inch neolon to cut to be the top cover of the orthotic (also purchased JMS Plastics).

Bottom view of the top cover glued and applied.d

Top view of the final trimmed product.

Closer view of the wings and top cover in place.

Close  up view of the leather, poron, and neolon around one side of the heel cup.

Getting Better Heel Stability with Orthotic Devices

Here various materials are used along the medial and lateral borders of the heel cup to obtain getter stability out of an orthotic device. 

When Are Orthotic Devices Too Old and Should Be Replaced?

Collection of Custom Made Orthotic Devices


Patients present almost daily with orthotic devices made in the past  and want to know if they  are still okay to wear or should we make new ones. There are several common generalizations out there from every 2 years to every 5 years for rigid or semi-rigid orthotics, and every 6 months to one year for soft orthotics.
 I tend to take a different stand on this. First of all, I never want to see the orthotic (to avoid judging a book by it's cover) device until I have seen how the patient functions in it. Some pretty horrible looking orthotic devices work great and some high tech super duper ones look terrible at controlling the abnormal forces.
This week I had a patient Marilee in to evaluate her 20 year old orthotic devices, and they functioned just fine. I stole them for just one day to do standard refurbishing of the non plastic parts. And because she has somehow gone from 44 to 64 years old, I changed the posting on the heel to softer materials for more shock absorption. A little kinder on her knees which can bother her.
And there are times that new orthotic devices are made to change the purpose of the orthotic device used. So  basic orthotic devices used to stabilize the foot for plantar fasciitis in 1996 may not be stable enough or soft enough to help a knee problem in 2011.
Therefore, the general rules of keeping it simple stupid (KISS) do seem to apply here most of the time. The Orthotic Devices can be Too Old when they stop giving great function and allow the patient to walk and/or exercise better, when symptoms seem to be stubborn and orthotic changes may help, when new symptoms normally necessitate a different type of orthotic device all together, and of course, following foot/ankle surgery when the foot is now a different shape.
This only takes a little more thought than some protocol stating every 2 years or so whether the patient needs it or not. 

Duplicate Orthotic Devices for Experimentation

Today my patient Linda had a second pair of custom made orthotic devices dispensed. In the photo above, the newest pair with the spit polished leather is on the outside of the older pair. These 2 pairs are identical. Are they for pure luxury? No, Linda's situation is like many patients where her first pair of orthotic devices are doing very well, but not perfect. She still has some symptoms, but her function with the orthotic devices looks ideal. Does the practitioner experiment with an orthotic devices which are doing very well, and where the experimentation may ruin the orthotic device, or does he/she make a duplicate pair for experimentation? This new 2nd pair will be used for my multiple experiments to make good even better.

A Fix For Squeaky Orthotic Devices

When foot orthotic devices with some plastic, mix with modern day shoes with plastic or rubbery components, squeaking can occur. I have always recommended with some modest success that the patient apply foot powder under the orthotic device inside the shoe and around the sides of the orthotic device to act as a friction layer. For the shoes that this is not enough, you must find out where the squeak is coming from and apply leather to the orthotic device in this area.

Here the pen is pointing to a layer of thin leather (that any shoe repair store has) that has been glued/superglued to the sides and back of the rearfoot post on the orthotic device.

When the patient presented with the squeaky orthotic device, proudly walking for me to prove it, vowing on a stack of Bibles that powder had reduced but not eliminated the squeak. So I carefully put my hand on the orthotic device inside the shoe (yes, this is why I earn the big bucks!! What dangers lurk!?!), and attempted to move the orthotic device to produce the annoying squeak. It seemed to reside loudly in the heel area. Since this type of orthotic device had plastic posts, I covered the posts with leather and made Stacey walk. Wallah, no squeak!! Yes, it is hard to stay humble.

Rebuttal New York Times Article on Orthotic Devices

http://www.nytimes.com/2011/01/18/health/nutrition/18best.html?ref=science

First of all here is two comments from my patients.
Patient #1:

They just never wore the ones you make! Signed Shirley to me!!

Patient #2:
Dear Dr. Nigg:


Orthotics are the greatest invention since corn flakes! I may very well be one of the first people to wear them, having obtained a set in 1959 (they were made from plaster casts of my foot of 100% cork in those days and suggested by my Podiatrist Dr. John Pagliano, of Los Angeles. His son, Dr. John W. Pagliano, DPM, is a famous sports medicine Podiatrist in the greater Los Angeles area).

My current pair are state-of-the-art orthotics made by Dr. Rich Blake, DPM of St Francis Memorial Hospital (Catholic Healthcare West) in San Francisco. They have cork heels. They aid in preventing of my previous lower back problems and sore arches.

Sincerely,

Richard

      I want to thank Shirley and Richard for bringing the New York Times Article to my attention. I have been practicing for 30 years, average making 200 pairs of orthotics per year, giving me 6000 pairs of orthotic experience to bring to this table. And I am Past President of the American Academy of Podiatric Sports Medicine, and Past Editor for Sports Medicine of the Journal of the American Podiatric Medical Association.
      Orthotic devices are shoe inserts prescribed for a specific function, normally to relieve pain. And the orthotic devices must make the patient walk or run more stable, more fluid, with less stress at heel impact, produce better alignment at pushoff, be comfortable, and so on. These are heavy demands placed on the prescribing doctor/therapist/orthotist, but the sophisication is there to accomplish these goals. The advances in the orthotic industry have been so immense in my 30 years in practice that I find poor orthotics only made by those disinterested in the process. The patients demand success. And success is normally delievered by the health care system. I am very proud of my podiatric colleagues for their work in this regard. There are podiatrists, like myself, that specialize in orthotic devices. But, great orthotic devices are being made all over.
     Much of Dr Nigg's comments (and I respect him immensely) show he does not dwell in the world of foot pain. My last patient of the day Toni will never ever take Dr Nigg's comments (and I hope he was just misquoted). Toni had severe foot pain, 4 years ago orthotic devices eliminated that pain, and you can not convince her to not wear her orthotics. And I do not blame her!!
     In my practice, I make routinely probably 20 different types of orthotic devices. And I take very seriously my need to get it right since many insurance companies will only pay for one pair a year. I do not have the freedom of a researcher to experiment away with every patient. So I try to analyze what type of orthotic device is appropriate for this patient with these symptoms at this time. It does not mean that this patient could have 10 reasonably different pairs made for them, each doing something alittle differently, each affecting different change at their feet, ankles, knees, and hips.  But that would be so confusing to the body. I am glad I do not have to research these changes from subjective data from the patient.
     Orthotics Work Wonders!! I believe that because I have see that every day in my practice. Many patients can not consider walking a step without them due to nerve damage in their foot that no strength gain in their foot could ever compensate for. Who is Dr Nigg to send negative energy into this realm? Medicine is all about healing, about hope, about positive energy. Orthotics, even in the most challenging patient, with the most difficult symptoms, are a symbol of that hope. I know enough about the world of orthotic devices to know that if they fail to help a patient it is because I am not understanding the situation enough. It has nothing to do with orthotics, it is the imperfect humans prescribing them. I ask Dr Nigg to do research on how long it will take a patient with nerve damage to strength their feet so they can avoid orthotics all together?
     Why do patients get orthotics? They are in pain, and their mechanics seem to indicate that some change produced by an orthotic device would be helpful. So they get orthotics. The pain goes away. Some good research should be done on how long should the patient remain in orthotic devices after it cures their problem. The average patient does not want that pain back. They may be very happy to wear orthotics forever, like I wear my eye glasses. Yes, I should do some eye exercises, but I am taking the easy way out. Yes, I need to have all my orthotic patients doing 2 to 5 minutes every evening foot strengthening exercises. So, they won't be so frail.
     So, I applaud the New York Times for bringing this to the forefront. Being from San Francisco, where William Randolph Hearst made yellow journalism famous, I understand how you want to sell papers. But, why don't you give hope, because orthotic devices have stood the test of time in medicine, and deserve praise for how well they have helped millions over the last 40 years since modern day orthotics were introduced to the world by Drs Root, Weed, Sgarlato, and Orien. Boy, have they changed the world. I, and my patients, salute you gentlemen.
  Thank you. Dr Rich Blake    
    

Top 100 Biomechanical Guidelines #37: Major Stability can be Attained with Full Root Balancing of Forefoot Deformities

Taken from Root Lab brochure. Dr Mert Root, my teacher, my mentor, my friend. I miss you. Passed away after a long illness in 2002.
http://www.root-lab.com/about.htm

Dr Mert Root, along with several other brilliant doctors (Weed, Orien, Sgarlato), revolutionized the treatment of foot problems with their theories in the 1960s and 1970s. A Balanced Root Orthotic Device is the standard that all orthotic devices are modifications. To design a balanced orthotic device, you are eliminating the intrinsic tilts in the foot, the forefoot varus, forefoot supinatus, forefoot valgus, forefoot pronatus, plantar flexed first rays, plantar flexed fifth rays, etc, etc. Being a purist, Dr Root preached full correction of these corrections. Disciples followed that espoused modifications for comfort, sometimes they were right and sometimes they ruined the technique. Most labs will make the classic Root Balanced Orthotic Device if asked, but their standard is their version of a  Modified Root Balanced Orthotic Device (normally function loses to comfort). But, the debate will rage for decades whether the purest 100% correction of these natural tilts in the foot is that important, or whether 80% correction is okay. Or 70%. Or 60%. I believe it is important when using the Modified Root Balanced Orthotic Device to clearly document what type of correction you are using. If the symptoms are not improving, further correction towards the classic Root Balanced Technique can be ordered. I know this works, and will dedicate a few posts to this topic. I use so many types of orthotic devices, but the Root Balanced Orthotic Device is the best for many conditions. These include:

1. Morton's Neuromas
2. Hammertoes
3. Midfoot Sprains
4. Metatarsal Fractures (including Jones type)
5. Metatarsalgia
6. Tailor's Bunions
7. Pes Cavus Problems

I hopefully will be able to introduce you to Root Balancing. I owe it to Dr Root, an unbelievable giver, and healer. His son Jeff, and daughter in law Kathy, run his lab still, even though Dr Root passed away in 2002. A terrible loss.

These are forefoot varus impression casts of the foot. When you stand them up, they lean inward. A Root Balanced Orthotic Device will attempt to place these heels straight up (heel vertical)

These are forefoot valgus impression casts. When you stand them up, they lean to the outside. A Root Balanced Orthotic Device will attempt to stand them straight up (heel vertical).

This is simply an introduction to a hot topic in podiatry. As more and more labs go computerized, and the health care provider has less and less control of the final product, the consumer may have to be more demanding. I have made a good living converting modified Root Balanced Orthotic Devices to classic Root Balanced Orthotic Devices to achieve better stability and better symptom relief. Talk to your podiatrist whether they use classic Root or modified Root techniques. Root technique is like the paint brush however, the individual provider must have the freedom to paint.

Top 100 Biomechanical Guidelines #36: Root Balancing Key to Correct Forefoot Abnormalities

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Happy New Year from Dr Rich Blake!!

 Podiatrists, and many physical therapists, make orthotic devices and other biomechanical decisions based on balancing the patient's forefoot abnormalities. When the primary function of the orthotic device is to support structural problems in the foot, the orthotic devices is called a balanced orthotic device or Root balanced orthotic device. Dr Mert Root, the founder of modern day orthotic devices, first published and lectured extensively on this subject in the 1960s and 1970s. It is still to many health care providers the only way to treat patients. The next few weeks I will be discussing the biomechanical guidelines surrounding this type of approach.

     It was the 1980s that the next explosion in biomechanics occurred with the development of Corrective orthotic devices with Biaxial sectioning, Inverted technique (my invention), Kirby Skive, and other modifications. Here the foot was modified to correct the forces of pronation more than could be accomplished by Root balancing or modified Root balancing. Here will be many posts on these sections.

Ah Chihuly!!

 This is the typical appearence of the outside or lateral arch in a Root Balanced orthotic device. The foot is suspended off the ground along the lateral side of the foot. This is crucial in supporting feet with many injuries including metatarsal fractures, neuromas, ankle sprains with instablility, etc.

Now see the mold below. The lateral arch is filled in. This is more like an OTC orthotic device now and loses its effectiveness for many injuries. 

Below is the orthotic device designed around Root Balancing. See the great lateral and medial archs. With this type of orthotic device, there are times when you can not tell which is the inside arch and which is the outside arch. Root balancing is classic podiatry and since it can be more harder to get used to, it is commonly lowered labs whom want to make a comfort orthotic device. Unfortunately, the effectiveness of the orthotic device may be greatly sacrificed. This the the common look of an orthotic device for a forefoot abnormality called forefoot valgus or plantarflexed first ray.

        

Top 100 Biomechanical Guidelines #32: Stress Fractures and Joint Arthralgia treated with Increase Shock Absorption

     Shock Absorption is needed following the impact (collision) of the foot against the ground. The shock wave that radiates up the leg is approximately equal to your body weight with normal walking, increases as you increase speed or go downhill, and can measure 2 to 5 times body weight with normal running. It is this shock wave that needs to be reduced to help many avoid injury by changes in shoegear, changes in surface, changes in shoe inserts, and custom made shoe devices. The King of all is the Hannaford Device. Hundreds of my patients have benefitted over the last 25 years, and I am hopeful to spread the word on how it is made.

     Hannaford Orthotic Devices, developed by Dr David Hannaford while practicing podiatry in Eugene, Oregon, are 2 layers of 1/2" plastazote material vacuum pressed around a mold, and then ground into shape to fit a typical athletic shoe. The layer of plastazote material against the skin is memory foam, soft in nature. The second layer of material is white plastazote, firmer and more durable in nature.

Impression Casts are used to make a Hannaford Device.

The 2 sheets of plastazote are cut with the memory foam full length and the white, more durable, plastazote cut to sulcus length (just behind the toes).

The length of the soft plastazote is approximately 1 and 1/2" longer than the foot and will be trimmed after the molding to fit better.

This is how the 2 pieces will be pressed with the softer memory foam against the foot.

Before vacuum pressing, both pieces are glued with Barge Cement so they will become like one after the press.

Before pressing, the toe area of the mold is covered with a soft material to flatten this part of the press. Without this, the memory foam molds around the toes too much. You need the orthotic to end up longer than the original foot.

The 2 pieces are placed in the convention oven heated at 475 deg F. Because the white layer heats up slower than the pink layer, the white layer is placed down on the surface.

Within the convention oven, the plastazote material is checked every 20 seconds and removed when the toe area begins to brown. A spatula is used to remove, but it can be handled gently with your hands.

Here it is centered over the mold with overlap around both sides and front and heel. You need to get as far forward in the press as possible for the best press. See the memory foam layer is being placed against the foot.

Once the press is started, you need to push down from the sides to help the vacuum remove all the air. The press is normally done in 20 minutes/foot.

After the press, wrap the mold with plastic wrap tightly for 1 hour to let the material cool completely in the shape of the mold.

Once removed from the wrap, mark the front length approximately 1 and 1/2" from the end of the mold, and mark the sides the exact width of the foot. Since I have a video of the grind, I will let that finish this post off.