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  • The Bottom Block: Gait-Referenced Casting and Design Part III
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    Welcome to The Bottom Block Part III Gait-Referenced Casting and Design
    Production of this Present lecture was made possible by a generous grant from Sole Supports. We make people better. At the completion of this lecture, stay tuned for a short presentation by Sole Supports.
    Before looking at the casting, let’s look and see what’s the most common biomechanical fault in gait can be. Over-pronation is clearly the most prevalent; about 95% of people over-pronate. Under-pronation is fairly rare, about 4%. Inadequate range of motion, they could have lack of ankle dorsiflexion, tight Achilles tendon and gastrocsoleus, functional hallux limitus due to elevation of the first metatarsal usually, restricted leg rotation, or lack of internal or external rotation can cause problems, and tibial/genu varum or valgum.
    Keeping that in mind, let’s look at the gait-referenced technique for MASS Position Casting. In this casting technique will be passing weight through the foot in as close to an ideal gait cycle as each patient can tolerate with their individual anatomy.
    Well, how does weight ideally pass through the foot? The heel contact on the lateral side come up the lateral across the metatarsals and out the great toe.
    So what position do you want to put the foot in? We’re proposing the Maximum Arch Subtalar Stabilization or MASS Position. This is a totally different position than neutral position. What we’re doing is putting the rear foot to tarsus in the maximal amount of supination it can stand when the heel and forefoot are flush to the floor. To do this, we put the foot through the same sequence of motions that occur in as close to an ideal gait cycle as we can recreate. Hence, gait-referenced. This makes this technique very individual person to person and foot to foot.
    Now if we are going to make a truly custom device, that is the device is going to mimic the shape of the test, the casting technique must be accurate. Part of this is because this is a very aggressive technology. We don’t want to over correct. It has to be repeatable, so we install a frame of reference. Unlike plaster casting, using the floor as the frame of reference. Closed Chain, the functional orthotic device is primarily functional in the closed chain. Therefore we cast in a closed chain and it follows an ideal gait pattern in as close to an ideal gait loading pattern as the patient can tolerate with their anatomy. This is why we call it the Maximal Arch Subtalar Stabilization or MASS Position.
    To do this, we’re going to use a box of urethane foam. We leave the socks on. Patient will be wearing the orthotic with the socks on and it smoothes out the skin lines making less plaster work necessary. Urethane foam is also very sensitive to moisture and the socks help insulate from that. But make sure you pull the socks up to remove any wrinkles. Avoid extremely thick socks. Now socks are not absolutely necessary if the patient is barefoot. You can cast barefoot.
    We’ll be looking at the Right Foot Casting Sequence. Simply reverse you hand positions for the left.

    First, we are going to have the patient seated on the edge of the chair. We center the foot in the foam, front to back, leaving a little extra room on the lateral side of the foot.
    We then slide the box so that the knees directly above the ankle in both sagittal and frontal planes. Remimicking a midstance position.
    The last plane we have to deal with is the transverse plane. By internally rotating the foot, you can cause supination or externally rotating it, you can cause pronation. So you want to get the foot generally in line with the thigh. So I use the second metatarsal as the reference and I’ll try to align the second metatarsal of the foot in line with the with the bisection of the patient’s thigh.
    Next I place my right hand across the patient’s right knee using my fingers on the outside of the knee to prevent the knee from abducting.
    The left thumb goes on to the surgical neck of the first metatarsal. You can move the knee out temporarily to get your thumb under then move it back.
    While holding the forefoot in inversion, we do a vertical shoulder thrust that is place your right shoulder on your right hand that is still on the patient’s right knee and do a vertical thrust completely bottoming out the heel of the foot
    Some practitioners have difficulty applying enough vertical force. So they can use their center of gravity on the knee that is press down on the sternum.
    Weight generally comes up the lateral side so we are going to take all eight fingers and place them between the fourth and fifth metatarsals of the lateral foot and do a vertical thrust not grabbing the foot and turning it, just pushing vertically straight down between the fourth and fifth metatarsals.
    Again, remember to completely bottom out each step of the technique. The floor is your frame of reference. One of the most common mistakes people make is not adequately bottoming out the styloid process or the base of the fifth metatarsal.
    Next, plantar flex the metatarsophalangeal joints. I like to use my thumbs on the toenails and completely dropping the toes to release the windlass effect. Otherwise, the foam will apply an artificial force dorsfilexing the toes tightening the plantar fascia causing the plantar fascial groove to appear in the cast.
    Next, palpate the head of the first metatarsal. You will be pressing just proximal to the joint. If you press too distally, the first metatarsal won’t be adequately bottomed out. Too proximal will cause a drop in the arch.
    You could then use two thumbs to bottom out each metatarsal head. I like to put one thumb across the metatarsal head and the other thumb just distal on the proximal phalanx. But pushing them both down together, usually you don’t create a shearing force on the joint and it’s a little more comfortable to the patient.
    Another way to make it more comfortable is to put some soft material over the metatarsal heads. In this case we use the small piece of EVA but you can use Spanco, molo, plastizote, or rolled up washed cloth works excellent
    Now work your way across from the first over to the fifth or vice versa, it doesn’t matter which direction you go but completely bottom out each of the metatarsal heads. One of the most common mistake that people make in this casting technique is either 1) leaving the first metatarsal head too high or 2), causing a transverse arch that is not bottoming out the lesser metatarsal heads
    It’s a good idea to go back and re-check, put a little more pressure on the lateral side, a little more pressure on each one of the met heads to make sure you have completely bottomed them out
    The final action is the thrust along with root described as the subtalar axis from dorsal anterior medial toward the part where the heel generally contacts the ground. This is a light thrust to seat the heel, just in case when you press on the metatarsals, you may have rock the foot forward.
    Now the same hand is making the thrust that was on the knee. If you’re doing the right foot, you’ll be using your right hand on the right knee and your right hand to make the thrust. This is a very light thrust just to seat the heel. Don’t move the heel backwards. That will miss-position the arch.
    Then lift the foot and evaluate your cast. Check to see that the forefoot is completely bottomed out and all on the same plane. Check that the heel is on the same plane as the forefoot.
    One of the best ways to check your cast is with the pen. We call this the pen test. Because the pen is a cone-shape object, the deeper you put it on the foam, the larger hole you get. S0; press on the center of the heel, the center of the fifth metatarsal head and the center of the first metatarsal head just enough to touch the cardboard. This should yield three equal sized holes which indicate that the heel and forefoot are on the same plane. Feel across from the first to the fifth metatarsal. Make sure this is not a transverse metatarsal arch.
    Here is a video of doing the pen test. The heel, the fifth and the first metatarsal. Remember the fifth is a little shorter than the first. If you feel across from the first to the fifth, you’ll see they’re on the same plane.
    Now if you fail the pen test, that is one of the holes is much larger, you may have to put the foot back into the foam to re-impress that area. In one case, on the left the heel’s too high. On the right ,the first metatarsal is too high.
    Now if you fail the pen test that is significantly larger put the foot back and re-impress that area. Then redo the pen test. The only you really can’t fix is if you thrust in the wrong direction, that final thrust, if it goes toward the arch it may collapse the arch. In which case, you’re going to just have to recast the foot.
    Now if you fail on the heel, it is probably a good idea to get your thumb under the first metatarsal and invert the foot again or supinate before re-impressing the knee and bottoming out the heel.
    Here’s a video review of casting of the right foot. Patient is seated on the edge of the chair. Pull up the socks. No wrinkles. Foot is placed in the center of the foam leaving extra room on the lateral side. Slide the box so the knee sits directly above the ankles in both sagittal and frontal planes. Turn the box in a transverse plane until the second metatarsal is approximately in line with the thigh. Then place the right hand across the right knee, left thumb under the first metatarsal head while inverting the forefoot bottom out the heel lateral side, release the windlass effect by dropping the tips of the toes, then work your way across the metatarsals with your thumbs bottoming out each metatarsal completely. Recheck the lateral. Recheck the lesser metatarsals and the first metatarsal. Make the final thrust then lift the foot out of the foam, and you’re done.
    Let us take a look at this from the top view. The patient is seated on the edge of the chair, socks up, no wrinkles, foot in the center of the foam, extra room on the lateral side, knee directly above the ankle, second metatarsal in line with the thigh, right hand across the right knee. Left thumb under the surgical neck of the first metatarsal, maximally invert the foot while you do a vertical shoulder thrust. Impress the lateral side with all 8 fingers between the 4th and 5th metatarsal tips of the toes to release the windlass effect. Work your way across the metatarsal heads and completely bottom out all met heads. Re-impress the lateral, double check the met heads, then hold down the first met head with the left thumb of a light thrust with the right hand plantar, posterior, lateral.
    Now, we are going to assess the patient’s forefoot flexibility using the modified Gib test. So for the right foot, we place the left palm around the back of the patient’s right heel. Grab the first metatarsal keeping fingers and thumb hyper extended, so the tips of your fingers and thumb are not on the foot. Then rotate around the stable fifth metatarsal.
    Let’s go over that more step by step. You place your left hand around the back of the patient’s right heel, take the right hand, hyperextend the fingers and thumb, and with the web space of your right hand, grasp the patient’s first metatarsal, the fingers and thumb are both off the foot. You are not pushing on the foot medially and laterally. Basically, you are rotating your wrist or elbow around a stable 5th metatarsal. You are determining how flexible the patient’s forefoot really is.
    Remember, when rotating around a stable 5th metatarsal so in performing this test, you should see that the 5th metatarsal stays stationary.
    Imagine if you were looking from anterior to posterior, from the tip of the toes toward the heel and you were looking down on a protractor with the center of the protractor on the 5th metatarsal. We are trying to determine how much rotation around that 5th metatarsal is possible for this patient.
    We made a simple 1 to 5 scale; 5 being the most rigid and 1 being the most flexible. If the patient can barely move, say 0-5 degrees, we call it a 5. 5-30° we call a 4. 30-60° which is the normal, we call it 3. 60-85° we call it 2. And over 85°, we call a 1.
    Let us go over some common mistakes done in casting. One is that you allow the knee to drift laterally and you are not making a vertical thrust. You’re coming down at an angle.
    This will create a thrust where the lateral heel wall appears slanted outwards, the heel impression seems inverted, and the medial heel wall has kind of a foam “overhang” or a cliff.
    Another very common mistake is not bottoming out the base of the 5th metatarsal adequately as some patients do have a high lateral arch. In those cases, it will be captured in this cast but very often, people leave too high a lateral arch when it’s not really there anatomically.

    Another common casting mistake is placing the fingers into the arch as opposed to putting your thumb under the head of the 1st metatarsal. This causes an impression of the fingers on the arch of the foam making it difficult to estimate what the actual arch is.
    In young children, you may decide to add or use a lower seat or pile up some boxes to bring the ground up to the foot.
    Once you have an excellent mass position cast, how are you going to design the orthotic?
    What does custom mean anyway? It should mean that the shape of the appliance mimics very closely the actual geometric shape of the foot. Custom design means that there are no pre-designs. No sporthotic, marathotic, or embriothic. Every single orthotic is custom, custom-designed for that patient’s individual foot.
    What are the design criteria? What are the parameters? We are going to look at the patient’s body weight, foot flexibility, diagnoses, shoe type, the activity level, and certain special considerations.
    Here is a typical design form.
    Throwing out the top of most design forms is relatively easy and self-explanatory.
    To calibrate an orthotic correctly, the lab needs to know if the orthotic will be put through very heavy duty use. For example, are there going to be prolonged periods of standing or heavy lifting.
    As far as foot flexibility is concerned, remember a more flexible foot needs a more rigid orthotic. In a flexible foot, the ligaments are not helping, so the orthotic has to apply a much greater force to control the longitudinal arch.
    Conversely, a rigid foot needs less support because the bony and ligamentous structures are all ready supporting the longitudinal arch. Therefore, the orthosis needs to apply less force to maintain the arch.
    This is where you record the measurements that you took when doing the modified Gib test.
    It is essential to know the body weight of the patient. See more weight means more force passing through the orthosis with every step. Therefore a patient that weighs more needs a more rigid appliance. A patient that weighs less needs a more flexible appliance. Now, if a patient gains or losses weight, this could cause the appliance to become miss-calibrated. If they lose about 15% of their weight, they would have to have the orthotic recalibrated. If they gain more than 15% of their body weight, they will probably need a new orthotic.
    It is always a good idea to weigh your patients because people lie about their weight. Now if the patient is pregnant, it is a special problem. Some doctors use the pre-pregnancy weight. Others prefer to add about 30 pounds, and then if the patient loses the weight post partum, then they have the orthotic recalibrated. The orthotic should function pretty well for weight changes 15% above or below which is right.

    That will help you in the design and step 3 is just to make you conscious of what type of shoe you are designing it for. Casual means any roomy shoe or tight shoe, does it have a removable insole or not, and that will tell you how much top cover you could fit in or is it a tight-constricting shoe, and then again does it have a removable insole or not. Heel height. If there is a discrepancy between the heel and the forefoot, like a high heel, it is good to know how much because the orthotic comes with the lateral side very flat and will curve it for the high heel. Now the bottom box works as sandal. New sandals ship with this form, that’s because if you want the orthotic to be fit into a sandal, it is a good idea to send the sandal that has a removable insert to the lab with your orthotic orders so that they can fit it directly into that sandal.
    Some examples of constricting shoes are dress shoes without removable insoles; cleats like soccer, track, football; skates, hockey, figure and rollerblades; cycling shoes are especially constricting, alpine ski boots; and cowboy boots.
    Like what I said earlier is that if you put your orthotic in a high heel in a lateral side of this flat, it rocks inside the shoe. The patient experiences walking out the back of their shoes.
    A simple test to see if that is the problem would be to put the orthotic inside the shoe and rock it forward to back. If it rocks, then you need to adjust or bend the lateral side to the curvature of the lateral side of the shoe.
    Next, you will choose the height of the heel cup. In a shallow heel cup, you get the narrowest orthotic; that’s good to fit into a very narrow dressy shoes, but would move around inside an athletic shoe. A medium heel cup fits most athletic casual work boots and the deep heel cup really adds more stability to the arch. Therefore, it’s good for very severe over pronators, that’s people with long low flexible arches and patients who you want especially good control of the arch that is for a competitive athlete for example.
    So to review, a shallow heel cup is narrower therefore good for constricting ladies dress shoe or slip-on shoe or sandal and also good for less active use.
    Have you tried to fit a deeper heel cup into a ladies dress shoe, you’d see it pooch out at the back of the shoe. That back of the shoe holds the foot on and when you pooch out at the back, this is the second reason why patients walk out the back of their shoes.
    The patient thinks they are walking out at the back because the orthotic is too thick. If you were to gauge caliper the center distance, the depth of the heel cup, you would see that it is thinner than a CD. A CD in this case is 1.19 mm; The orthotic measuring at 1.15.
    The medium heel cup fits most athletic casual work shoes, and is easily calibrated to deliver the correct force that the arch needs in walking, standing and light jogging.
    And for high impact activities or people that carry heavy loads, do prolonged standing or just has really severe pronation, it is a good idea to use a deep heel cup because the depth of the heel cup actually buttresses or flanges the plastic on the medial side making it stiffer. It is one way to increase the rigidity of an arch.
    So quick review, shallow mostly for dress shoes, medium for most shoes, and deep either for the competitive athlete or the patient is doing heavy loads, prolonged standing, or has really severe hard to control pronation.
    Next you will decide how wide should the shell be. The widths determined from the plaster positive, not the shoe size. We can by the cast whether they have a wider or narrow foot. What we are asking is relative to that foot, how wide do you want the plaster?
    If you want wide for example, you should get the full width of the plaster positive. This is good for diabetic or insensate feet. Anyone that has kind of a fleshy foot that might hang over the medial side of the orthotic and cause the orthotic to become irritating, something we called arch bite.
    The standard shell width comes at about 3/16th from the medial and lateral edges of the cast fits very well in most casual and work boots while providing adequate support.
    The narrow shell width fits best in the narrow type of shoe like a constricting ladies dress shoe or a bicycling shoe.
    Quick review; narrow for the ladies dress or very constricting shoes; standard for most shoes, and wide for the fleshy and insensate foot that might hang over the medial edge.
    Next you will choose the length of the top cover. Full goes to the end of the shoe, sulcus to the ball of the foot, and met head to the end of the plastic or just proximal to the metatarsal heads.

    Here is an example of the met head length, the sulcus length and the full length.
    There are several options in materials. You can use a cushion foam material, an ultra suede, or an ultra suede with cushion foam.
    The cushion foam comes in two thicknesses, 1/8” and 1/16”, in blue and black and it’s a high rebound shock absorbing foam with excellent durability. The ultra suede is paper-thin comes in five colors and looks identical to real leather, has an excellent coefficient of friction.
    This chart is basically self explanatory; it just shows standard usual combinations that are used in orthotic construction or design. A lot of people used standard full length eight inch top cover usually with ultra suede, works well in most casual shoes with a removable insoles and it’s good for general use in casual shoes with a removable insoles but it holds the position in the shoe very well especially in runners to prevent the orthotic from sliding back and forth and usually is able to prevent runners toe when the tip of the toe keeps hitting the shoe causing a subungual hematoma and loss of the nail. Standard constrictive shoes usually are going to use a pretty thin top cover maybe a 1/16” of cushion foam with ultra suede. If it’s very constrictive, you only want to go met head length and if it is in a lot of tight shoes with a removable insole, it’s pretty versatile because it’s easy to slip in and out of the shoe. The maximum thickness you can go with the top cover is 1/8” and 1/16” in most shoes unless you go into a double or triple depth shoe. You can use cushion foam 1/6” plus 1/16” with or without ultra suede, of course with ultra suede is much better, it holds it together better, but with a casual shoe deep definitely has a removable insole. It gives a lot of shock absorption, a good soft cushion to stand on and it’s good for the elderly patients who have lost some of the fat pad that they need especially under the metatarsal area. Minimum thickness would be about 1/32” now with the ultra suede only. I usually don’t recommend it because it’s so easy to feel even the slightest imperfections through the ultra suede only. Met head length, you generally go with ultra suede only, you could not really have it just hang off into the shoe or it would bunch up. So you use it only for the very tight shoes. It gives you the most room for the foot but very little cushioning.
    Here’s another quick review slide. Full length for most shoes, 1/8” cushion foam. Again, prevents orthotic from sliding, gives you good shock absorption and has the most design options. Sulcus length is kind of an unusual length, it’s when the patient has hammertoes and if you put something under the tip of the toes, it will cause the hammertoes to hit the shoebox and maybe rub a corn or an ulcer but you’d like extra cushion under the ball of the foot because they have lost a lot of the fat pad under the metatarsals so then the sulcus length is appropriate. Met head length is usually used in a very tightest and constricting of all shoes like bicycling shoes and slip-on ladies dress shoes.
    Once you have chosen the cover length, the next thing would be to choose the cover material, the color and the thickness of the cushion foam.
    In choosing the cover material, it is really better to use the ultra suede over the cushion foam as opposed to the cushion foam by itself because the cushion foam has poor coefficient of friction that is it grabs the skin unless that’s the desired effect. So generally you will want ultra suede that is to stay below or with the dotted line. Choose your color and then decide which thickness you’d like, 1/16” for the very tight constrictive shoes, 1/8” for roomier shoes. If you want a sandal orthotic, it is best to just send the sandal in and we’ll design the orthotic to fit very well into that sandal so we can determine based on the sandal the correct heel cup height, the correct material, the correct even color of the top cover and the plastic.
    Now if you want to send in the sandal with a removable foot bed that the patient has already tried on for size, fit and comfort, we’ll fit our shell and top cover to match the sandal bed. We usually use a black plastic or black cushion foam and maybe black ultra suede. The heel cup size will be relative to the indentation on the sandal. The sandal orthotic may fit in some other patients other casual shoes if they have a removable insole.
    On the back of the former, some, optional modifications like met pad kit, heel lift, cushion extension, cutouts and child’s outgrowth policy.
    Let us get to heel lifts first. Generally, you don’t need as much heel lift with this technology, why; because very often limb length discrepancy is actually a functional change as a result of asymmetrical pronation. When you’ve given the patient as much correction as they can tolerate, very often that leg length discrepancy disappears.
    As far as heel lifts, most athletic shoes will accommodate about 3/8”. You want to correct about half of what you measure because measurements are very inaccurate. A lot of time, slip on dress shoe whether men’s or ladies’ just won’t take any heel lifts. It will cause you to walk out the back. Above 3/8” will sometimes require you to get an extra depth or a high top shoe. A lot of times you can add more heel lift by shoe repair shop or by a Pedorthist.

    Some patients may ask for some full foot lifts like for a ski boot. It provides lift without plantar flexing the ankle. We just cut it out from a piece of cork and put it loosely in the shoe under the orthotic.
    Sometimes you want an extra little extra cushion onto the ball of the foot. So you can add an 8th or 16th inch of cushion extension, starts on to the plastic and goes to the sulcus of the foot. You want to do it bilateral in the vast majority of cases because you don’t want the patient to be out-of-balance. You can add cutouts in the ___ extension or on the cushion foam on the top cover itself. This gives the patient extra shock absorption and depths for those cutouts. The most you can probably fit in any shoe is about 3/16”.
    If you like cut outs and if your corn is not really for ulcers, it takes some weight off the metatarsal head especially if they already have a lesion. Mostly you will put in the cushion foam extension but you may decide to put it in the top cover itself, it could be unilateral but the top cover thickness should be the same on both sides. To accurately mark the correction, it is very critical for success.
    One way is to just take a marker and mark in the foam the exact place where you would like to cutout.
    Another way is after you are finished casting, remove the sock. Put a small adhesive pad under the lesion and put the foot back into the foam, then press on the top of the metatarsal head and the felt will transfer the impression into the foam in the exact correct position.
    A long-time favorite is the use of met pads, generally not as necessary with this technology. It works by putting pressure in the shaft of the metatarsal taking it off the metatarsal heads. I would only use it if the patient is extremely tender under the met heads during the acute phase of inflammation. Sometimes you can use cutouts instead, but if cutouts aren’t working and you want additional relief, you can add a met pad temporarily and put it sticking it into the top of the cover allowing you to move it around until the patient has it in the right position. Generally it’s not recommended that you put a met pad under the top cover because then to remove it, the top cover has to be replaced.
    Additional information can be added in step 8 and also there’s a place on the bottom back on the form. Put any pertinent medical information like the diagnosis. Ask for technical call. Put in any unusual modifications you would like to the orthotic. Draw a picture if you like.
    With an orthotic as aggressive as this, it is very important that you break it in slowly. The sole support will radically change the way the muscles contract; some earlier, some later, some longer, and some shorter. Therefore, it is imperative one hour to first day, two to second, add an hour every day until you get to eight hours, then you can wear it all the time.
    How was the patient going to feel when this orthotic is dispensed? We’re making a radical change in the way they walk. We’re changing the position of their foot. We expect them to feel different. If they didn’t feel different, we wouldn’t be doing anything. So they can feel certain muscle contract earlier, later, longer, and shorter. They are going to get, kind of, adult growing pains, maybe some muscle fatigue. It’s a good idea that they stretch their calves. When you dorsiflex the calcaneus, you tighten the gastrocsoleus. Now if somebody is going to change their activity radically, it is a good idea they repeat the break in period. Maybe run one mile, and then two miles. Don’t go run the entire 12 miles in the orthotics on the first day. It is a good idea to wear the orthotics almost all the time at work and at play. It is not a good idea to go from corrected to incorrect to corrected to incorrect back and forth. They should probably wear the orthotic at least 85 to 90 percent of the time that they are weight-bearing.
    Rigid feet have a harder time getting used to the orthotics. Maybe you’ll slow down the break-in to half an hour a day. Like I said stretching exercises are very important. It increases the range of motion and especially necessary to prevent early heel lift which causes the patient to walk out the back of their shoes.
    It is a good idea to follow up the patient. We recommend 3 weeks and 3 months. Perform a Fowler Test. See if there is a good generalized contact still between the foot and the orthotic. Remember timelines for break-ins can vary from individual patient to patient. Be patient, this is a transitional period. The patient is changing the way they walk. The goal is to get the most function out of the foot in the first ray. So remember hallux limitus, rigidus, arthritic conditions on the foot and the knee may take more time to adapt to change. Sometimes in active patients you will see some evidence of rubbing or chafing in the arch.
    If the arch friction becomes excessive, you might. Want to consider changing top cover, maybe going to the ultra suede. If you’re already using that, you might want to make a slicker top cover by taking a piece of clear packing tape and placing it over the arch to reduce friction between the sock and the orthotic. A little talcum powder can help. Socks that wick away moisture generally have a better coefficient of friction like Smart wool. Also you may decide to slow down or make the break-in more gradual especially for high impact activities.

    What if the orthotic squeak? You can sprinkle some talcum powder in the shoe or use some postal packing tape but usually talcum powder works.
    When and how should I adjust sole supports?
    Firstly, you need some materials like paint stripper that we found in a paint department of the most large hardware stores. Leather gloves and a cup hook to hang the paint stripper where no patient goes.
    Some safety considerations; the silver part gets very very hot. When you first turn on one of these paint strippers, you might burn in the coils, in other words, burn off protective coating they put around the coils which may make a little of smoke. Wear gloves. Use a cup hook and place it where no patient goes. Inform your staffs that the silver part stays hot.
    When do you adjust the sole support? When maybe the patient is not getting complete relief, or the relief has hit a plateau, or they initially got relief and now the symptoms have recurred, maybe because the plastic has dropped a little bit, or the patient just cannot tolerate the orthotic. In that case, make sure that the calf muscle is not too tight.
    Now should I raise or lower the arch; because the patient has the same complaint â€" arch pain. Usually that is because the arch is too low. The patient is dropping down and hitting the orthotic with each step. The patient is also then losing correction. If the arch is too high like pressing up too much into the foot, that’s very very rare. Why? Because in this casting technique, you are bottoming out the metatarsals giving them as much arch as they actually can tolerate. It is possible; however, that the orthotic is too rigid in applying too much force in which case it would have to be recalibrated. Our goal is to give you the appropriate amount of full contact with just the right amount of support and flexibility.

    So the orthotics has arrived and you are dispensing them, you’re going to trace the medial arch against a piece of paper on the wall. I will show you the picture on the next slide. Record both arches left and right for future reference. Put it in a chart. A little bit of arch loss may be 1/8” is expected due to regular use within the first 3 months and that is called creep. Progressive loss over the first 6 months indicates that probably we need to remake the orthotic with a thicker material because we miss-calibrated it.
    Here is a picture of tracing the arch of the orthotic on a piece of paper against the wall.
    The first step to determine if the arch needs to go up or down is to perform the Fowler test.
    The procedure is very simple. You place the patient in a casting position. Knee directly above the ankle, 2nd met in line with the thigh. Leave the ball of the foot on the ground and lift the heel to about 45° to the floor. Lift the orthotic against the foot, keeping the shell flush to the foot. Watch the knee is still straight and directly above the ankle. Check for gaps in the arch.
    If there is a space between the foot and the orthotic, that tells you that the patient still has a range of motion available in the direction of supination that could be used to attain additional correction.
    So if there is space between the foot and the orthotic, then there is still range of motion to get more correction, you might want to consider raising the arch. Use this as an educational tool also to show your patient the difference between a full contact orthotic and a typical orthotic. The patient may come in with a bag of orthotics; Fowler test all of them. Show them that you can stick 4 fingers between the foot and the typical orthotic when this test is performed. That is how much your foot has to pronate before it even touches most orthotics. If the apex of the arch on the contrary digs into the center of the arch which is extremely rare, then you will know you will need to lower the arch.
    To do any adjustment, you must first heat the plastic. Wearing gloves use your paint stripper to focus the heat on the bottom of the orthotic between the medial and lateral borders. Move the gun in a circular or figure 8 pattern crossing in the middle. Avoid singeing the top cover or bottom vinyl by staying away from the edges.
    First you will notice, the plastic gets a little shiny. At this point, you might want to stop and check for ease of distortion. You know, put it on a countertop, gently pressing down on the heel and the forward edge and see if you could lift the arch or lower it down.
    If you are using the black plastic, then you begin to heat it, it looks like the picture on the left, and when it is ready to adjust, it looks a lot like the picture on the right.
    Try not to overheat the plastic. If it feels resistant to change, put a little more heat on and recheck it. The plastic should retain some spring while being reformed and yet be pliable enough to allow the reshaping with moderate pressure.
    Remember to wear gloves. In these pictures, the gloves were just in a way. Press up on the arch with both thumbs and pull the orthotic ends towards you with the ulnar sides of your hands.
    Then place the orthotic on a flat surface and hold it in a position you would like for at least 25 seconds to let it set.
    Always remember to allow the plastic to air cool about 15-20 minutes. Then recheck the arch site. You can check it left to right on a flat surface or check it to your line diagram or to your tracing of the orthotics against the wall.
    A video review of orthotic adjustment. Heat the plastic first to get it a little shiny. You will notice a wide ring forming around the area that is hot enough to adjust after you remove the heat. They you put it on a flat surface and start reshaping the arch the way you would like it. In this case, we are raising the arch. Once we have it in the position we like, we hold it in that position for about 25 seconds. If you would like to lower the arch, it is a very similar procedure, same heating but then put pressure on the arch to lower it. Another way to put pressure on the arch is to slide over the arch with your thumb and then hold it down in position until it sets.
    If the relief you get after adjustment is only temporary, try raising it one more time and if it still doesn’t work, call technical support who will probably advise you that the orthotic has to be remade in a different plastic thickness, usually thicker, or we need to change the trim lines to make it hold and shape better. These modifications and remakes should cost you nothing.
    If the patient just cannot tolerate the sole support, it is very unusual but possible that you over supinated the foot during casting. Usually the patient just needs to slow down the break in period and do more calf stretching. On rare occasion, the orthotic is too rigid. Try flexing the orthotic with the palm to compare left and right. Then call technical support for advice. The orthotic may have to be recalibrated.
    Once again lowering the arch is very similar to raising it. Heat the orthotic, place it on a flat surface, and press down evenly on the arch. Avoid any focal pressure that might deform the orthotic. Hold it for about 25 seconds. Once again, always air cool then recheck it arch to arch or against your earlier tracing.
    The high heel modification is because the patient may be trying to put the orthotic in a shoe with a slight heel causing the orthotic to rock. Perform the test. See if it rocks. If it does, heat the lateral side of the orthotic, make a slight lateral arch, let it air cool, and retest it in the shoe again to see if it rocks.
    Let us just look at some trouble shooting; potential collapse issues. Sometimes, the patient may be such a severe pronator that they put so much pressure in their arch that they pronate right through the orthotic. They have a medial roll-over, tarsal splay. Maybe they have a considerable increase in the amount of weight-bearing that they do in their activities of daily living. It could be that their regular activity is high impact or involves heavy lifting or carrying. The most difficult to control foot is a long low arch profile in a very flexible foot. Those could be extremely difficult and may require the orthotic to be made very, very stiff.
    One modification that does stiff in the orthotic is to raise the heel cup or even put a higher medial flange on the orthotic. This creates an extra deep heel cup on the medial side and an extra wall of plastic that bridges from heel to arch as well as flanging the plastic making it more rigid.

    If you suspect that the patient will collapse the orthotic because of a long low flexible foot or excessive amount of pronation, you might consider erring on making the orthotic a little more rigid. One way to do that is to tell us the foot is more flexible, use a deeper heel cup, consider a possible high medial flange especially for the severe over pronators, and sometimes you could even specify, I would like the plastic be a 0.5, 1 or even 1.5 mm thicker.
    As a point of advanced trouble shooting, there are some patients that have tolerance issues. Some patients are very sensitive like those with very rigid feet like Charcot foot, extreme cavus, maybe fused anatomy; they can be postsurgical or post traumatic patients; some patients that have chronic pain and inflammation in their feet, for example fibromyalgia, patients with multiple pain sites in the lower chain. Some elderly patients are extremely sensitive and then there are those that are just difficult patients.
    So if you suspect these patients may have potential tolerance issues because of any of the aforementioned conditions, you might side on a higher Gib test score. In other word, tell us the patient’s foot is more rigid so we make the orthotic a little more flexible. Consider extra cushioning foam on top as the top cover maybe 3/16” cushion foam for maximum accommodative effect especially if the shoe will allow it. Consider lowering the orthotic just a little bit or casting with the arch just a tiny bit lower. Remember the orthotic is only one tool for treatment. You could also use various stretching modalities, anti-inflammatories, etc.
    Always remember to listen to your patient. The patient has a piece of data that you don’t. How it feels. They might say move the arch forward or back. They are usually right. Or they may say smooth out a particular area.
    The 80/20 rule or the Pareto principle states that about 20% of the people when you introduce a new technology actually get it. They are seeking out the best quality care for their patients despite the demands of new learning and new procedures. The other 80% are just resistant to change. Sole Supports technology tends to appeal to that 20%. Sole Supports are very effective tool, and practitioners should expect to be more involved in understanding how best to use orthotics.
    How to ship an orthotic.
    It is a good idea to fill the cavity with either toilet paper or a soft batting material often used to fill pillows. These two methods of shipping, you can send it to Federal Express or priority mail.
    To get certified in this technology without attending a live workshop, we are requiring you to finish 3 perfect test casts. To avoid confusion, write your name and phone number or email address on the test cast label. Stick the enclosed FedEx shipping label on the box, and call 1-800-GO FED EX for a pickup.
    The orthotic casting box should fit perfectly into FEDEX large white box, and then you stamp a 2-day billable stamp on it and call 1-800 GO FED EX to set up an account for regular pickups.

    Technical support in Sole Supports is unlimited and free. Just call the toll free number between 8:00 and 4:30 central time.
    The in-lab turnaround time is 3-5 days plus shipping both ways. Shipping time is dependent of course on carrier and distance. Rush service, if we receive it by noon is out the same day. It is the next day if received afternoon. Warranty work is always an automatic rush at no charge.
    Our warranty is simple. The plastic shell is warranted for 1 year against cracking. You can buy an extended warranty for 2 years if you like. Top cover guaranteed for 6 months. Most design modifications are free for 6 months. You have 6 months to get it right. Sole supports will be replaced for heat adjustment damage at no charge during that first 6 months. If you are going to send shoes, please insure them.
    The simple no questions asked return policy. 50% credit to your account after reasonable attempt to correct any problem within 6 months from the date we ship your orthotics. Sole supports are adjustable so make every effort to make them work for the patient. We don’t make cash refunds. We credit it to your account. For quality control reasons, you want to put a return/credit form with the return request. Now when you want credit to your orthotic, the orthotic must be returned unless other arrangements are made.
    Payments Net 30. Most of the credit cards are accepted except Diners Club. A lot of times, people use credit cards on file and just have us charge it once a month. You can send a check with the cash but make sure you staple it to the form so that it doesn’t get lost. If you want us to accept the patient check, then there is a 50% up-charge so whatever it costs, add 50%. We attach the invoices to the outside of the shipping box so the patient doesn’t see them and once a month you get a statement that lists all your activity for the month. If you string us out over 30 days, we charge the standard 1.5% per month 18% APR finance charge.
    Insurance coding is different with different companies and in different areas of the country. It is best to call each major insurance company for their coverage on foot orthotics and durable medical equipment. Check your state association for coding recommendations. Typically, doctors charge between $450-$500. I have seen even $600 for this product. Encourage the use of flexible medical payment plans that the patient may have to cover the cost of the orthotic if the insurance doesn’t cover it. Ask if there is sales tax on durable medical equipment in your state. You can check your state law with your state society.
    Different materials to help you explain orthotics better to patients are available like brochures, posters and patient education sheets.
    To become certified in this new technology, send at least 3 perfect test casts with the stickers of different feet. As shown earlier, use the FedEx labels included in the supply kit. When we receive 3 casts that pass our inspection, you will receive a customer number and a certificate of training; request additional free boxes at anytime from customer service, if needed, to begin casting your patients. Feel free to call our technical support for assistance as necessary, or visit us online at solesupports.com.
    We have tried to make our website a valuable educational tool with downloads on “how to ..” documents, exercises, letters of medical necessity, patient education sheets and a whole lot more.
    Congratulations! Pending receipt of your 3 casts, you are now certified as a Sole Supports provider. We operate on a single core value, that is we make people better and we want to take this opportunity to thank you for caring enough to give your patients the very best.

    Production of this PRESENT lecture was made possible by a generous grant from Sole Supports.. We make people better. Now stay tuned for a short presentation by Sole Supports.
    Sole Supports is an innovative and rapidly growing custom foot orthotics lab founded in 1992. It was created by Dr. Edward Glaser in order to provide a more effective alternative to the traditional custom orthotics that are based on the work of Root et al. To accomplish this, Dr. Glaser developed a radically different theoretical analysis of common biomechanical faults, a casting technique based on the ideal gait loading pattern, and a full contact orthotic device capable of altering foot weight-bearing function.
    We are unique in that, unlike typical custom foot orthotics labs, we do not base our technology on neutral position casting. We are also unique in that we custom calibrate every orthosis to insure the proper balance of flexibility and rigidity needed by every individual patient. Additionally, we make every orthosis to maintain full contact with the patient’s plantar foot in our corrected MASS position. We do not “cast correct.” Why? Because that lowers the arch and diminishes the correction.
    Only Sole Supports give you: Gait referenced casting, MASS position correction, full contact support, no cast correction, calibrated flexibility.