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Laser scanning vs casting: Yes or No!

Discussion in 'Biomechanics, Sports and Foot orthoses' started by nicpod1, Apr 21, 2010.

  1. BEN-HUR

    BEN-HUR Well-Known Member

    I have a feeling I could be a passionate guy :eek: .

    Yes, I understand the dilemma in some cases.

    I did do this to some degree with TOG in regard to the above cited case (& there were others) in my previous post. I tried 3 times with TOG (with the above case)... I gave up & went with someone else.

    Yes, I understand. There are far too many potential variables to my liking... depending on the lab you use & the methods they employ. It also depends on the methods the practitioner employs as well... as to how the lab interprets the cast, your associated prescription & subsequent desired result. I have attempted to reduce these variable factors as much as possible to the point where what I envisage is what I hope to get back.

    However, I have been thinking over this issue for quite a while now, hence the reason for clicking onto this particular thread. I have been thinking there must be a more accurate/reliable way... or should I say a more accurate way of receiving a custom orthotic in what you (the practitioner) believe is adequate for the patient.

    I have been thinking of methods of obtaining a more adequate process for orthotic therapy. I have thought/wondered if the obtaining the image of the patient's foot in your (the practitioner's) desired position in digital format is the most efficient way to go. Direct laser scanning (or is it 3D optical) of the foot I thought would be the best way to go. Once this is achieved I believe it would be best for the practitioner him/herself to do the orthotic design on their own system (with a particular software package) whilst the patient is in the clinic or shortly afterwards. This way the practitioner who has the intimate knowledge of what is required for the patient (i.e. correction, orthotic shape for desired footwear etc...) has the role of doing the designing. The results of this could be emailed to your desired lab that has the technology to use this information to then fabricate the device. In other words, this method offloads the responsibility from the lab of the interpretation of the cast & prescription notes & is just responsible for the manufacturing of the device. If there is a manufacturing problem then it is an issue for the lab... if it is a design (i.e. shape, correction) problem then it is an issue the practitioner needs to address. I can see so many benefits for all concerned under this method as it removes the guess work & potential frustration from all concerned. Each sector has their responsibility for the desired outcome.

    Does anybody know if this type of method is being done or if there is adequate hardware & software for this to take place? I understand there will be some financial outlay for this method to take place but I wouldn't think it be too much for the practitioner to sacrifice considering the potential savings on money, time & peace of mind.

    I wasn't aware that labs even had responsibility of this. I thought it was the practitioner’s discretion as to the orthotic shell thickness/stiffness based on their patient’s weight.

    I personally use a thinner shell material but have the underside of the orthotic (i.e. ILA) filled in (usually contoured to shell shape) with my desired EVA density (based on the weight of patient) to obtain the desired flex & desired (tolerable) comfort for the patient. If the device is too stiff/aggressive I just grind some of the EVA away, the orthotic flexes a bit more & all is well.

    I am unsure of the context of this statement.

    True... this is my point. However, they do also claim to scan casts/foam foot impressions (if they are sent in) as well... I also doubt this with my experience... or if they do, does the scan get used to manufacture a device based on the specific scan of the foot in question. The scan does give you an outline of the planter pressure of the arch... but what does this mean & what use does it play with the manufacturing of a custom device. The surface of the ILA could be 1mm off the surface of the sensor pad or 20mm off the pad & still give the same result!

    *** Do people want to know what TOG's reason was as to my lack of adequate results with their system? I'll paraphrase... As I am a Podiatrist I would naturally see more specific foot related abnormalities than say a Chiropractor would... hence the difficulty in meeting my expectations :bash:. Now, that's a loaded statement with all sorts of implications :butcher: i.e. their system can only address certain types/degrees of conditions?... their system is designed for who exactly?
  2. joejared

    joejared Active Member

    Approximately $20.00 in materials (12"x24"x1" polypropylene) can produce 4 1/2 to 5 pair of devices, + royalties, where applicable. Prefab devices typically cost $6.00 to $7.00 per pair in bulk. One new customer is aware of this, in that he can simply make his own prefab styles on demand instead of in bulk, for approximately $5.44/pair. Still, the difference in cost per pair for manufacturing is roughly $1.00 per pair and a bit of casting and design time. Some of my customers do actually manufacture prefabs, but usually, it's less than 0.5% of their normal production, almost not worth mentioning.
  3. CraigT

    CraigT Well-Known Member

    Agree 100% with respect to an ideal system. We manufacture everything ourselves here as there is no lab that can logistically help us. We currently have an Amfit system which we use to mill positives and then vacuum form shells however this still requires input from us during the manufacturing process (as well as some other limitations).
    The only system that I have found out there that does anything like what you suggest is from Delcam. Rather than just plugging in numbers, you do get to see the design as you go. We are looking at installing it here to ensure that we have less time in the lab, but still have truly bespoke orthoses. I have always made my own devices, and am very fussy- time will tell if this system does the trick.
  4. Ok, just for fun, I'm going to do a Simon.

    Would such a system would be more effective if the process above were used with a pre fab base, rather than a cast of a foot?

    If not, why not?
  5. CraigT

    CraigT Well-Known Member

    Why would it be more effective?
    Could it be just as effective? Perhaps... depends on how it is measured.
    I believe that the most effective orthosis will have a good reflection of an individual's foot morphology. I prefer a shell type of orthosis, and this type must fit the foot well to be comfortable and effective. Shell type prefabs cannot be modified enough to reflect the morphology (as well as not being able to build in intrinsic correction such as a medial skive, inversion etc), while I don't get the level of control I desire with a moldable orthosis as it will be either soft, flexible or both.
    The digital lab as described above is also more repeatable.
    Having said that, it is not to say that the method you are describing cannot be effective- I believe the most important aspect of orthotic therapy is that the practitioner has a reasonable mechanical aim, and they design a orthosis to achieve that aim and then assess the effectiveness of it.
  6. Ian Drakard

    Ian Drakard Active Member

    I agree with Craig- if it's more effective with a prefab base it implies something wrong with our custom design, but that's not to say a modified prefab couldn't be as effective in the right circumstances. The foot doesn't care how the orthotic was made- if it applies the required forces to the foot and is well tolerated by the patient it will help.
    I use a mixture of modified prefabs, non custom CADCAM and custom CADCAM orthotics depending on what I'm trying to achieve. All have their place.
  7. Why? Given the variation in the morphology of the foot depending on what position it is placed in, is there a single "morphology?" Intertester variation for ff rf position for casting can be up to 16 degrees, there is a lot of potential positions / morphologies.


    Really? I can think of shells I've made which are in positions I could not cast the foot in which are effective.

    What about the systems like starflex or sidas?

    More repeatable as in can make identical insoles from one scan, yes. More repeatable as in being able to scan the foot twice and get the same result, any evidence for that?

    (attourny at law for Mr B L Zebub.)
  8. RobinP

    RobinP Well-Known Member


    What is the name of this system. Only I think I have seen it and cannot remember the name. Is it the one where you can have a choice of capture method - calibrated callipers/scribing arm/flatbed scanner?

    The design is changed as you make each modification so that you see an updated image of the orthses every time it refreshes?

    I'm curious because I wanted to look into the same thing


  9. RobinP

    RobinP Well-Known Member

    OK, Here's my effort..

    I use a large percentage of custom to CADCAM orthoses so I'm not really saying that this is my opinion - I'm just trying to think about what you are asking

    The majority of patients requiring orthotic input are going to be wearing footwear purchased from a shop, therefore the last of the shoe will be relatively generic. Even assuming that the patient were to have orthopaedic footwear made for them, the majority of this is based on standard last shapes which are adapted for greater width and depth(cosmesis of a lot of bespoke footwear leaves a bit to be desired.)

    So if the shoe/orthotic interphase is critical to the function of the orthotic and the shoe/orthotic combination is what will ultimately change the tissue stresses, the base of the shoe (ie bontex or similar base layer) will dictate the size of the orthotic on the inferior surface and the dimensions of the rest of the shoe will dictate how big the orthotic can be elsewhere.

    If these assumptions are borne in mind, then homogenisation of an orthotic has to be essential and therefore, a prefab base would be preferable.

    I can think of many examples of patients who have a measured heel width which exceeds the inner dimenisions of the heel of their trainer. I take heel widths in non weight bearing, full weigth bearing and in full weight bearing with a set of callipers simulating the medial to lateral squeezing of the heel that a shoe would make. All of these measure exceed the heel width of the trainer. In order to manufacture the appropriate device for this pateint and their footwear, I am required to make the dimensions of the orthotic the same as the trainer. In effect, I am completely homogensing the device, the only real customised element is the arch contour, which is arguably being adapted in the lab without my knowledge(they claim they don't)

    Robert, I know you use foam boxes. Do you modify the foam impression immediately after taking the impression in order to minimise your lab work? If you do modifications such as arch infills, how do you assess how much is required? How good is your reliability at measuring the degree of arch infill - so you decide it needs a deep arch infill 9mm - how accurately are you able to measure this on the cast? I've seen people using nails but surely that must have a 10-15% variation in the measurement alone?

    So anyway, I think it depends on the types of devices you are making. If you are 4 deg medial wedge with 3mm medial heel skive kind of person, then arguably it probably has less effect to use a prefab base than, say, the person doing the Blake style inverted devices with othere modifications beyond my scope of understanding or reading(at this point)

    I'd be amazed if anyone gets this far reading this as I've become quite bored writing it. I'm sure I could be more concise

  10. CraigT

    CraigT Well-Known Member

    By morphology I am referring more to the contours of the foot such as arch profile including the plantar fascia, the shape of the heel, the contour along the lateral column...
    There might well be intertester variability when you look at angles such as ff-rf on the cast, but I am more interested in how well the finshed product maps the foot. It will not be perfect as there are changes due to additions that you prescribe, but I have a personal preference that when I put the orthosis against the underside of a person's foot, I can see clearly that it is made for them. Often this is more art than casting.
    I like that you can get more specific control in 3 planes, there is less footwear influence (eg : not shank dependent) and they can be less bulky to provide a greater amount of support.
    I am not sure what you mean here. I have not said anything about casting or casting techniques, yet you have mentioned it again. Matthew mentioned above about the practitioners 'desired position', and I think that is what is what you want to capture. It is what you do with it from there is what counts. That can be radically different from the cast foot.
    It is my belief that generally the stiffer/ more rigid an orthosis, the more the fit and function is important. Most pre-fabs are flexible because most people would not tolerate a rigid pre-fab- don't you agree? That is not to say that you cannot have effective pre-fabs or soft devices- gees... that is pretty much all they make in continental Europe (and Scandinavia... right Mike?).
    We have a Sidas system. Their blanks are very good in football shoes- but we press them over our positive models, and usually after the athlete has a pair of polypro devices for their trainers. We will also reinforce them with carbon fibre for stiffness if warranted.
    We are still experimenting with their silicon bladder casting system, but I can only see myself using it for situations where only moderate control is needed.
    Don't know starflex. I have seen the pictures, and it has potential to be used with our sidas casting system, but again you cannot add the same variety of instrinsic and extrinsic mods- except if you pressed it over the model as above.
    Not referring to the scan- digital scanning has all the limitations that other casting methods have. However it is faster and cleaner. If you can get the desired copy of the foot and manipulate it in the manner you wish, then it should be superior. When I am saying it is more repeatable, I am referring to the fact that if you create a digital orthosis, you can repeat it easily and know it will be identical, and you need not even see the patient to make it again(not that I am advocating this).
    If you make up some modified pre-fabs, and the patient want a second pair either immediatley or some time down the track, there is greater chance that it will not be the same, and also you need the patient to be there to mold them (if this is part of your original design). It is simple variability of a hand-made device- it should not be overly significant with an experienced practitioner, but it is there.

    When we are up and running with out system, we should be able to scan a patient, then make multiple pairs of orthoses which are identical apart from 1 prescription variable- sound good for research???
  11. CraigT

    CraigT Well-Known Member

    Delcam Orthomodel and Orthomill
    I have been impressed by the progress they have made in the software over the past couple of years- they listen to feedback.
    They also now have a laser scanner which also seems very good.
    We will hopefully have a system up and running this year- insh'allah (god willing)
  12. Correct and I got told the other day that hard orthotics are from the 70´s and soft EVA is the `new`technology, when I suggested it was about the force required from the orthotic as to what material required( soft, hard etc) to have the desired affect. Equal and opposite force and external moments and all that, I got very strange looks from a couple and 1 lightbulb moment from one in a group of physios, baby steps.

    For what it´s worth I´m also looking at Delcam, I´ve had some conversation with a couple of pods who use it and looking at their website looks the best to me. I was going to look at the system this April but the ash cloud got in the way, maybe next year.

    I also hope as the system improves the costs will come down, hope at all that.

    ohh look a :pigs:

    Also consider what are we doing with a cast/foam box or scan we are taking a image of a foot at a certain position, the foot will change it´s shape, position etc a huge amount during gait and different activities.
  13. CraigT

    CraigT Well-Known Member

    That's hilarious.
    The thing that I can't figure is that the people saying this seem to think that we haven't considered this... Do you really think that I would use these materials if they were 'too hard' for my patients? Gee... EVA, visco elastics... they have been around for only about 20-30 years. Very new.
    My only comment to these people is that yes, if the combination of fit and correction is not right for the person, one thing they may say is that they feel too hard. This indicates to me that there is something I have to change, and it is rarely the material.
  14. BEN-HUR

    BEN-HUR Well-Known Member

    Thanks for your feedback Craig. Are these the Delcam systems you have in mind?

    Thanks Robert for playing the devil's advocate on this discussion (at least I interpret this is the case). This topic does need to be scrutinized over... in playing the devil’s advocate helps test the quality of the methods we engage in & identify weaknesses in its structure/methodology/understanding.

    I personally feel the Podiatry profession should be the forerunner in orthotic therapy (that’s not to exclude the value of other professions contributing to the area). To do so we must have legitimate reasons for doing what we are doing (i.e. casting/foot modelling methods, parameters for orthotic prescription etc...). The following PDF is an interesting read... “Is There Proof in the Evidence-Based Literature that Custom Orthoses Work? With evidence to support it”...
    View attachment Evidence for custom orthotics.pdf

    However, more research is needed in the realms of orthotic therapy so its scientific/medical standing is more solid. At present there is a fair degree of ambiguity & objective interpretation in the midst of orthotic therapy. Despite this, orthotics has shown to work remarkably well over a diverse realm of pathologies. Yes, prefab orthotics does work in some cases... but is this adequate? What is the percentage/success rate of prefabs... & is it worth resting our laurels on this type of insole support? I think not. I feel we need to aim higher with our goal to eliminate the extent of ambiguity & objectivity from this form of therapy. I feel custom orthotic therapy has far greater potential in helping address & heal a much greater percentage of pathologies & subsequent individuals than the hit & miss (& hope for the best) prescription of a prefab or generic arch support in general. To think otherwise just opens the door for justification of the methods practiced by TOG, Foot Levelers, PCI etc... & any other wannabe device targeted at the feet which claims to cure an array of conditions. It also opens the door to others who do not understand the biomechanics of the lower limb & the role it plays in an array of various injuries.

    I worked in a practice which once issued someone else’s orthotics to another individual (I don't know how)... & yet they worked great. I have even heard that an individual was wearing their orthotics in the opposite shoe & yet they cured the condition. Changing/altering the adverse forces contributing to strain & injury is the key but I just wish to find a more consistent, reliable, repeatable process to doing so... where what I understand & envisage is what the patient gets every single time I prescribe an orthotic. It is only by doing this can we then get a clearer understanding of what we understand is reliable & subsequently the role orthotics play in the treatment process of various injuries. If a desired orthotic that we have prescribed does not work, we can then go back & look at the process (&/or our understanding) & ask how & why (i.e. would the device function better with more valgus correction etc...).

    Yes, I agree... this is the potential value of the digital orthotic therapy process. The technology looks to be now (or nearly) available for us to utilise. I remember years ago watching the Arnold Schwarzenegger movie “Total Recall” & thinking that the x-ray type scanner assessing people walk through a security zone would be excellent for assessments...

    The future of biomechanics looks very exciting & interesting as technology improves.

    Some very good points Craig. It seems we are on the same wavelength. This is the value of a forum such as this... to bounce ideas around with other clinicians who are doing what you are doing; thinking of potential more efficient processes to make our job more effective for us & our patients.

    I am very interested in this. For me it would be the OrthoModel & maybe the iQube scanner (I guess). Do you know the cost of such items off hand? Does anyone know how effective the iQube scanner is?

    Kind regards,
    Last edited by a moderator: Sep 22, 2016
  15. This is interesting:

    Also does anyone have a full text of: Sanner WH: Clinical methods for predicting the effectiveness of functional foot orthoses.
    Clin Podiatr Med Surg. 1994 Apr;11(2):279-95.
  16. RobinP

    RobinP Well-Known Member

    And the most important line from this paper.....

    On average, pedorthists and orthotists achieved a slightly larger pressure reduction in high peak pressure regions and a better walking convenience than podiatrists did.

    C'mon the orthotists!...........(tumbleweed blows)

    Kidding, we are well behind you guys for biomechanics. Didn't sound like the group of assessed podiatrists thought much in line with you guys(i.e.the pod arena massif)

  17. You should look at the perceived importance of pressure reduction between professions against what was achieved also the percentage of prefabricated components between professions too.

    I agree, I think the devices prescribed by these podiatrists were what we would term "simple" insoles. Lots and lots of problems with this study, but interesting none-the-less.
  18. P.S. Come on England!!!!!!!!!!!!!!!! for ****s sake you gotta play better than last Saturday.
  19. DTT

    DTT Well-Known Member

    Well at half time Si they need stuffing with the rough end of a pineapple mate:mad:

    What a load of crap !!!!!!

    Bloody national team ?? not ours I think.

    Send them all to the Tower and behead them and put their wages toward the national debt:eek:

    Lets hope the second half is more productive
  20. Ian Drakard

    Ian Drakard Active Member

    Have you been eavesdropping on the half-time talk ;)
  21. CraigT

    CraigT Well-Known Member

    Algerian Medical team is from my hospital- I have been looking after a few of the players...
  22. DTT

    DTT Well-Known Member


    I've seen better play at my Grandsons little league matches in the park.



    Perhaps if he knew the words to the National Anthem ( DUH ) he would understand what the fans were singing and draw some inspiration from it !!!

    Ashamed is an understatement, BOOOOOOOOOOOOOOOOOOO:deadhorse:

    And I don't even like football !!!!!!
  23. DTT

    DTT Well-Known Member

    Hi Craig

    Karma for you and your team

    They ran rings round our shower !!

    How much are our lot paid again ?????


    Perhaps the HPC should regulate them as well as us............:rolleyes:

    Well done again Craig:D

  24. CraigT

    CraigT Well-Known Member

    I should say we have been looking after a few of the players... they spent some time at our hospital rehabbing injuries and a Podiatry assessment and management was a component with both of us involved.
  25. Griff

    Griff Moderator


    Sorry for the tardy response - had a weeks hiatus from the arena whilst being out of the country. I'm in, although admittedly don't bring anywhere near as much as Spooner to the party (in funding/knowledge/understanding of stats/all of the above) so understand if the offer has expired now he's involved ;)

    Seriously though - happy to play a part in some way - drop me a mail

  26. Dave Kingston

    Dave Kingston Member

    This discussion brings up a lot of issues for our profession of supplying biomechanical solutions for biomechanical issues (no matter what your base qualification is).

    These age old discussions will always be answered by opinion I'm afraid as we just don't have the knowledge to answer all the questions about orthotic therapy.

    Having some of the great minds on here research the answers is the only way forward and I applaud the likes of Spooner et al for putting their money where their mouths are. It's the only way to go.

    A few observations from my less than great mind:

    1. TOG System

    Note, that in Ireland thjeir is ZERO regulation for provision of orthotics. I have dealt with patients that have previously been supplied orthotics (*cough *cough !!) by physios, physical therapists, biomechanical consultants (huh?), aromatherapists (yes you read that right), doctors (both MD's and consultants), osteopaths, chiropractors and other assorted 'people'.

    On a regular basis I have asked the TOG representatives for Ireland and the UK the following questions:

    1) How do you make a 3D devices from a pressure measuring device (2D) based on RS-Scan technology?

    2) How often does the GaitScan report the following - "Your biomechanics are normal and there is no need for any orthotic therapy"?

    3) How often does the GaitScan report the following - "Your biomechanics are beyond the help of orthotics and you need a surgical consultation/physio etc"?

    I am still waiting for satisfactory answers.

    2. Scanners vs Cast vs Foam Impressions

    I think the thing to consider here is the elimination of errors. No 'system' is fool proof.

    If your assessment, functional anatomy and prescription skills are lacking it doesn't matter what method you use. To this end I always make students take 'casts' until they achieve competance in casting a foot. I have found that if you are competent at plaster casting and understand the positves and negatives (no pun intented) then a good clinician can achieve a good cast using a laser scan or even a foam box.

    Basically, with no method being perfect, it is all down to the knowledge and practical skills of the clinician.

    Let the debate continue...until the great minds can come up with definitive answers.


    P.S. France - hahahahahahahahahahahahahahahahahahahahahahahaha!!!!!! Come on Henry, you cheating ************! (sorry for the Irish bias)
  27. Lets just get on with it. I'm sure we can all play NICELY together.
  28. Cody

    Cody Welcome New Poster

    I've spent the last 5 years working with different type of scanning technologies and so far the only technology that I have found to be on par with plaster casting is the "Structure Sensor" or "iPad scanner" as it is called in our industry.

    The Structure scanner uses a laser, both cameras and two receivers to accurately build a 3D model of any object. Movement is a key feature of this scanner, allowing you to capture true 3D which is usually not possible on a 2D surface or flat bed scanner.

    Accuracy depends on the app used. The hardware is great, but is designed for scanning large objects or even entire rooms. Some app developers have increased the density of the point could while others have not. The higher the density in the cloud, the more accurate the scan of small objects.... like feet.

    This scanner also allows me to hold the foot in neutral position (as I would with a plaster cast) while an assistant runs the scanner. It's faster, much cleaner, and extremely easy to use.

    *other scanners I have worked with - Both the iQube and larger Delcam model, the Tomcat unit and Lasermark 3D scanners. I gained this experience while working for Forward Motion Medical Orthotics out of St. George, Utah.

    For more information on the 3D app that I helped develop and to see the scanner in process visit our website (of which I cannot post a link because I am new to the forms, but a Google search for Forward Motion Orthotics should get you where you need to go :) )
  29. Phil Wells

    Phil Wells Active Member

    Hi Cody

    Thanks for the update on your experiences.
    I am currently trialing the Fuel3D scanner which has he advantage of being 'one shot' technology. Very fact and accurate but as it has a target disc that has to be included in the 'photo', it can restrict the foot capture - I find it hard to get deep heel cup capture but as this does not impact on my orthotics designs I don't mind.
    No assistant required when using and at £1000 its pretty good value.
  30. Boots n all

    Boots n all Well-Known Member

    We have been playing with different scanners recently. The main unit we have is brilliant, we are scanning for custom footwear, so we need complete foot and ankle, 20mm above melleolus. The I-ware Infoot is the best and quickest, but not every clinician can afford one, well over $20K.

    So we have been fiddling with the https://store.structure.io/store. $611 by the time it gets here, most can afford this. As to how accurate it is, l will let you know when we have finished our trials.

    First thing to note, the I-ware system scan is complete in 7 seconds, no holes, no assistance needed.
    The structure sensor is taking way longer and this can be a challenge when dealing with special needs clients, as they have to be still, perfectly still for an extended time. maybe 5 minutes?

    This is the app we are using for now https://www.youtube.com/user/Techmed3D
    The end game is more clinicians can afford this devise, it may result in Podiatrists emailing me their scans, from the scan we can modify, then we mill out the Last on our 4 axis mill, then make the CMF, all done remotely in 21 days?

    Technology has come a long way since l started back in the late 70's with plaster and there is still more to come.

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