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Casting and a good assessment, is that enough?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by footsteps2, Jul 13, 2009.

  1. footsteps2

    footsteps2 Active Member

    Members do not see these Ads. Sign Up.
    I am just setting up on my own and due to financial limitations initially I may not be able to afford a pressure foot scan system. Is a good Biomechanical examination along with proper foot casting enough? From experience have you found that patients like to see something visual to show them foot pressures, gait patters etc?? I will be using a video camera and filming walking which is how I determined any forefoot deformities previously (when I had access to a high tech scan, gait analysis system). I did find that there was never enough time to make use of all of the functions this system offered, which I felt was a shame but the patients liked to be able to see the results on screen.

    I am on a limited budget, can't really afford $250 a month to lease a foot scanner system (pressure scanner) and found that many pairs of orthotics that were ordered through a CAD type system had to be altered anyway, especially with the posterior MLA being too high and impinging. The scanners create a good template to locate base 1st met etc and to place heel cup in right place but you still had to select planus, normal or pes cavus arch profile which is the same as using a pre fab with a selection of arch heights!!

    It does seem to point towards good old plaster casting being the accurate method, providing the foot is held in right position when casting..

    With that in mind can anyone recommend a good orthotic manufacture clinic in queensland that I can send my casts to?

    Many thanks
  2. Craig Payne

    Craig Payne Moderator

    You can not get a 3D foot shape from a 2D pressure reading. They are a scam.

    If you needed to adjust all the orthotics you got from a cad/cam lab, then re-evaluate your prescription, don't blame the lab.
  3. PodAus

    PodAus Active Member

    Focus on the reasoning behind the clinical theories and relate to what you observe in clinic. Select what's appropriate for individual patients rather than 'the' biomechanical assessment for all patients.

    Forget 'computerised technology' at this point to do it all for you, although video analysis software can be a good patient education tool.

    A good working relationship with a lab takes time to develop, however as Craig said, it's all about your thought-processes in problem solving, which is reflected by your prescriptions.


    Paul Dowie :morning:
  4. Bit harsh isn't it Craig? Granted you can't get a 3d morphology from a 2d scam, I guess they use a library system for a shape they reckon will work for that foot based on the gait analysis data, but thats a little different from them being a scam isn't it!?

    Lets face it by they time most casts have been "corrected" the morphology isn't a great deal like the shape you cast anyway!

    Good luck with your clinic footsteps. I get my with my eyes, my ears and my hands*. Have done for years and people still seem to get better. I've just started a private clinic where I have video gait analysis and I'm liking it lots but I'm not sure it tells me much I did not already know.

    Great pt education tool though! :drinks.

    My 0.02$ is that if you know your stuff you don't NEED the toys (although its nice to have them), and if you don't know your stuff all the gadgets, gismos and machines which go ping won't help you.

    *Although it really hurts if you have to get your patient to walk over them more than once!:eek:
  5. CraigT

    CraigT Well-Known Member

    While I agree this is the case, my personal feeling is that it shouldn't be... I like my orthoses to look like they were made for that foot. ie: they are somewhat anatomical.
    Agree also- a pet hate is having a patient come in with a computer read out showing evrything which is wrong, including asymmetries, and a pair of identical orthoses which are, by all appearances, off the shelf. In addition when I have done the exam they report that the previous practitioner never touched their feet!!!:craig:
  6. footsteps2

    footsteps2 Active Member

    I actually find that comment quite insulting. I didn't have to adjust every orthotic, but the post MLA always seemed to be a little high (without selecting pes cavus arch), thats all. It was always an initial adjustment at fitting and no further adjustments..however, a colleague always had a ridiculous amount of adjustments to do so may as well have just made his own! My prescriptions were fine, i only ever did arch adjustments and not every time
  7. footsteps2

    footsteps2 Active Member

    Thanks Robert for the positive post! As said before I didn't have a problem with my prescriptions, forefoot posting, rearfoot etc always good and what I wanted..I learnt after a while to position the foot a little more forward and leave space behind the posterior heel which seemed to position to post MLA where it needed to be. That was more me getting used to the system, not my prescription as Craig T suggested. I am confident with my prescriptions but not so much with the actual making of the orthotics from scratch, i am on a budget and therefore cannot afford too much initially.
    My question was about whether or not anyone just uses their eye, a good biomechanical assessment and gait observation. i am thinking of using foam boxes, making cast and then sending off to a lab initially.

    I totally agree that you can have all the gear but if you don't know how to translate it then whats the point?!! I am no expert but I love Biomechanics and love that every patient is individual and nothing should be assumed!
  8. Craig Payne

    Craig Payne Moderator

    I have no problems with using library systems for prefabricated devices, but why dress it up with a 2D pressure system that can not give you a 3D foot shape. If that is not a scam, then what is?

    Agreed, you can use the 2D pressure platform as part of the assessment and to make it easier to convince someone to part with money, but as long as they are used and promoited as methods of getting a 3D shape, then what are they apart from being scams?

    No one from any of the companies can give me a better explanation of what they do, than use the word "algorithm"!

    I have no problems with using these systems or with people that use them, but PLEASE do not make claims for them that they are not. .
  9. Perhaps you just don't understand the algorithms?:rolleyes:;)


    As you say, if its dressed other than it is then thats not honest. Also not neccesary! I'm increasingly of the view that the idea of library systems might have legs (insert joke here).

    Was not sure if you were reporting or asking on the foam footsteps. If the latter then I think foam is good IF YOU KNOW HOW TO USE IT!

    You can bog it up just as easily as POP if you don't. Nobody picks up a roll of plaster and just "has a go" without being shown but people do with foam for some reason! I think thats why a lot of folk have trouble.

    CraigT, I tend to agree re the corrections. If I want an orthotic with a lower arch I'd rather cast the foot in a more pronated position than cast in a higher position and take a guess with adding plaster, but thats just me. I think the ethos of cast in neutral then add or take away to get to what you want is a hangover from the mindset we all struggle to escape that there is something inherantly noble about STJN and casting in it.

    Thats also a reason I like foam. With the reference plane of the ground you can SEE exactly what shape your orthotic can be and alter it your own self with your thumb if you want to.

    But that, as they say, is another story.

    If you hold to that attitude you soon will be an expert!
  10. I have a problem with labs that use a library systems for orthoses if they do not let their customers know that the orthoses they are providing to their customers are actually pre-made orthoses. I also have a problem with clinicians that tell their patients they are receiving custom foot orthoses when in fact they are using library orthoses that are premade. A library orthosis is nothing more than a pre-made orthosis that will need to be adjusted just as much as any other "good fitting" pre-made orthosis in order to allow it to become more therapeutic for the patient. I think we can all do much better than that for our patients, and our patients deserve much better, than giving them library orthoses.

    In addition, the use of a pressure mapping system to produce three-dimensional custom foot orthoses is a scam, just as Craig said. There is no way that a pressure map can produce a three-dimensional image of the foot. The only thing these pressure mapping systems do is to provide plantar pressures that occur on a horizontal plane. They do not, in any way, shape or form, provide sufficient information to accurately determine the plantar contours of the foot.
  11. DBannerman

    DBannerman Member

    Hey footsteps
    I'm an associate in a clinic where we have nothing but a good surface, our eyes, and our hands and we do most of our casting with plaster. We did use the gaitscan in school but it was more as an educational tool for patients - I think the between callus presentation, shoe wear, biomechanical assessment, and gait analysis (and/or whatever movement causes them the most discomfort), there's a good enough idea of what is going on on the plantar aspect of the foot without seeing a picture. I did really like it for ulcer offloading to ensure I wasn't creating a new high risk area with orthotics but otherwise I don't really miss it.
    I think patients are equally impressed if you can break down what is happening, how that results in their symptoms, and how your orthotic treatment will help.

    Slightly offside, do many people use a treadmill for gait analysis? I'm curious if people find it better or worse to get an idea of the patient's true gait. I've had a few runners in lately that only have pain with running but its hard to get them to jog in the hall because they're always accelerating or decelerating. I'd love to hear different opinions...
  12. A number of problems with this but that's for another time, another place.

    I deal extensively with runners, I should find my job pretty difficult to perform without my trusty treadmill. Try getting to grips with a 100m runner in your hall way. For sure, treadmill running is not over-land running and occasionally I have to go to the track, but of all the "tools" I use, it is the treadmill and slow-motion video that I find the most helpful.
  13. DBannerman

    DBannerman Member

    Sorry Simon,
    I may not have been clear on the ulcer stuff. It was the FScan insoles and they were not used to make the orthotics, just to assess if offloading one area was overloading another. It worked well with accommodative orthotics for neuropathic patients who didn't have the best habits for checking their feet for signs of pressure.
    I'd love to hear your thoughts on it - I'm a new grad with lots to learn and tons of time to do it in lol =0)
  14. footsteps2

    footsteps2 Active Member

    Do you have a camera at the front and rear of the treadmill..do you film from front and rear?
    I have decided against a pressure scan system. I am on a very tight budget but want to produce quality orthotics for my patients, impossible to get bank to lend you money when first starting out without much in the way of savings or regular income!!
    I have a treadmill, grinder, all my other equipment and just need a way of transferring images from the camcorder to the laptop!!
    The question now is how I start off with my orthotics. Am considering foam boxes, casting and then using the shell flex 3/4 shells which can be heated to fit the plaster mould and then add what I need in the way of rearfoot posting etc..only concern is I used to use forefoot posting quite a lot and can't find any shells that are full length!!
    I don't want the orthos to look cheap with bits added on all over the place...
    I am not sure I can afford a vacuum, oven etc at this time.

    I guess the other option is to send of my plaster casts to a lab for them to make up the orthos..any suggestions for labs in queensland??

    It is a dilemma!!
  15. Deborah Ferguson

    Deborah Ferguson Active Member

    I have resisted buying a scan/pressure system, preferring the `hands-on` method to assess patients.Presumably you cannot tie the underlying foot anatomy accurately to the pretty scan picture( unless somebody designs a magical scan/X-ray machine) which again makes it very difficult to prescribe accurate orthoses.
  16. Griff

    Griff Moderator

    You may want to see this previous thread regarding some of the various options. If money is an issue then you'll find post #3 by Tim by far the most interesting.

  17. Hmmm. The old "make your own vs buy in" debate.

    My advice would be to do both.

    There is a lot you can do with an EVA pre fab (of any description) if you have a heat gun, a grinder, some glue and some poron. Of course you also need imagination and a degree of aptitude with orthotic manufacture. If you lack the latter, don't even start! In my experiance lab technicians are born, not made. I've known some who have a real "feel" for it and others who just can't grasp it even after years of trying. So it depends on whether you are a "lab man" or a pure clinician.

    However in terms of making the top end, shell orthotics... I think you'd be wise to get them made professionally and pass on the cost to the patient. HAJ'ing it up will create more work than it saves.

    Remember also that your time has value. And its not just the time you spend actually making the things but ordering the stock, maintaining the equipment etc.

    So as with most things, its down to you.

  18. Craig Payne

    Craig Payne Moderator

    What are you going to do with the heat gun? You can't heat mold a prefab to the foot (another on of the great myths out there)!
  19. DaVinci

    DaVinci Well-Known Member

    Geez Paynie, do you ever sleep? Its 2.30 in the AM (I up with sick child).
    You need to do one of Paynies Boot Camps. Everything you just mentioned is usually covered. The Queensland one is soon. See this: http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=23975
  20. Craig Payne

    Craig Payne Moderator

    Its actually 6.30PM for me; I Boot Camping in Johannesburg.
  21. DaVinci

    DaVinci Well-Known Member

    Geez Paynie, are you ever home? The wife and kids have my sympathy.
  22. Can't heat mould it to the foot, no. But you can reshape the dorsal surface morphology to what you want. Higher / lower arch, depression for the 1st ray, PF groove, a pretty good analogue of a medial heel skive etc etc.

    And before you tear my head off and spit down my neck I KNOW that the shape will deform back to what it was before when a foot lands on it. Which is why you THEN need to grind the shank side flat and fill any voids you created.


    PS rotten luck Da vinci. Thats rough. Not swine flu I hope! Its going around schools my way like pokemon cards so its gonna catch up with us soon!
  23. footsteps2

    footsteps2 Active Member

    Thanks for all the advice from everyone.
    I think I may get a laser scanner, without spending an absolute fortune, and use it as a tool instead of POP casting. I am also coming around to the idea that the foot doesn't have to be in neutral (opposite of what I was brainwashed with in uni) and that it is important to see what the foot does in the gait cycle. The foot can then be positioned for the scan in the position I want. I am confident enough to do orthotic adjustments as in grinding MLA down, adjusting heel raise height etc but not to make them from scratch.

    I therefore think a good Bio assesment, gait analysis, scanner and enough grinder/adjustment skilld to make small adjustments is the way to go for me. I may even foam impression in certain cases and then scan the foam impression.
  24. footsteps2

    footsteps2 Active Member

    I think I will look into doing the August one in Brisbane, just going to look at flight options!! Thats the problem living in North Queensland, no local courses!

    Looks like the course is what I need...
  25. footsteps2

    footsteps2 Active Member

    I fully understand that pressure mats cannot produce 3D scans. What about the portable non weight bearing scanners..as they measure changes in depth do they actually produce an accurate 3D scan..I know that the scan is only as accurate as the position the clinician puts the foot in initially..which doesn't have to be neutral.
    I do not think they are necessarily a better alternative to casting but if you are not manufacturing the orthotics they seem to be a good aide. As long as the scan turns out how you want, then add the prescription, e mail it to the lab and then get them back in a week or so.
    My orthotic adjustment skills are not good enough to make them from scratch so it seems a good alternative for me at this time..of course, the lab has to also be good at what they do.

    I have been looking at the ScanAny system which they are just upgrading so that the computer is in with the scanner, rather than a separate laptop. The only down side of this may be if you like to show patients something on screen. I am aware that there are many scanner systems out there, non weight bearing, and some are going to be better than others. I have also looked at Amfit but these are pretty expensive.

    The ScanAny has a good promotional price on it at the moment and I like that they can produce full length EVA orthotics, which I am used to using and find easy to adjust.

    I will, of course, also be doing a thorough biomechanical assessment and gait analysis as well as taking a good patient history.
  26. Arjen

    Arjen Active Member

    There is much confusion about various optical scanners. I'd like to throw in my few cents. I don't have much of an axe to grind on this topic since aside from our foam box scanner, we don't trade in the optical scanner market (yet).

    Optical scanners fall into several categories:

    1. Document scanners. This is the same kind of scanner you use with your computer to scan in documents and photos.

    Some reputable manufacturers call these 2D scanners. This is correct. Others simply call them scanners, which is technically correct but very misleading. This type of scanner cannot produce contour data of any accuracy...period. If you want to see a sales guy squirm, ask them to scan a plaster casting and see if the device you receive fits the plaster casting.

    2. Laser scanners. There are several types of these, but generally they all work by projecting a laser or laser line against the surface and analyze the line with a camera. When a foot or any other object is placed in the field of view, the system, with a pile of software can generally accurately determine the shape of the subject. It results in trues 3D data. These systems can sometimes have issues with ambient light.
    Amfit's foam scanner works this way (it does not have ambient light issues).

    3. Structured light scanners / stereoscopic scanners. These scanners project an image of known size and shape against the subject contour and two cameras view the subject from two slightly different viewpoints. It results in a 3D dataset. There are also variations to this technique where a striped sock is stretched over the foot and two camera views taken. This technique offers almost instant acquisition. It also has widely differing amounts of accuracy. It is also subject to ambient light issues.

    -Arjen Sundman, President, Amfit Inc.

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