Welcome to the Podiatry Arena forums

You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members, upload content, view attachments, receive a weekly email update of new discussions, access other special features. Registered users do not get displayed the advertisements in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!

  1. Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
Dismiss Notice
Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
Dismiss Notice
Have you liked us on Facebook to get our updates? Please do. Click here for our Facebook page.
Dismiss Notice
Do you get the weekly newsletter that Podiatry Arena sends out to update everybody? If not, click here to organise this.

Custom made versus customised orthoses

Discussion in 'Biomechanics, Sports and Foot orthoses' started by markleigh, May 18, 2010.

  1. markleigh

    markleigh Active Member


    Members do not see these Ads. Sign Up.
    Having practiced for 18+ years, you'd think I'd be more confident in my biomechanical assessment & foot orthosis prescribing. However, a patient this morning with classic plantar fasciitis symptoms of less than one month duration. An everted rearfoot in gait, high supination resistance, delayed Windlass, normal ankle joint ROM, we talk about the cause of his footpain & recommend stretching, iceing, self massage & a foot orthosis to reduce the tensile forces through the plantar fascia. Can an off-the-shelf (OTC) evice relieve this gentlemans symptoms as well as a custom made orthosis is his question? My response was there is a greater probability of relief of his symptoms with the custom device versus the OTC device but is that backed by evidence??? I know about Karl Landorfs paper on OTC devices but what do you do with your prescribing of a device? Do you only use an OTC device if they say they can't afford a custom device or do you use an OTC in certain circumstances? Or do you only use custom devices, & not OTC's at all?
     
  2. Admin2

    Admin2 Administrator Staff Member

  3. Asher

    Asher Well-Known Member

    Hi markleigh,

    I use OTC devices mostly, but there are certainly times when only custom orthoses will do.

    OTC devices I can dispense on the day and I like to grind bits off / stick bits on according to what I have found from the biomechanical evaluation. It helps if the device is going to be worn in one particular shoe, or type of shoe, as they are shank-dependant and will work differently in different types of shoes. I like working with them. The bits I add / take off are just the same choosing the prescription variables when you fill out a script form for making custom devices. I review OTC devices 3 years after issue, sometimes they need replacing / changing, sometimes they don't.

    But as I say, there are times when only a custom orthosis will do. I find this is often the case in really roomy shoes like pull-on work boots. And I use custom devices where I just can't modify the OTC device enough eg: large transverse plane motion requiring a significant medial flange. The Interpod soft OTC device has a bit of a medial flange but often not enough. I review these after 3 years also, sometimes the covers / rearfoot posts need replacing, sometimes not. The shell rarely wears enough to warrant replacing within 10 years.

    I think both types of devices have their place. That's what works for me markleigh.

    Rebecca
     
  4. :good:

    I agree with Asher. Much depends on the type of foot and the type of person found proximal to it.

    There is no mystery to orthotics. They are simply bits of plastic which have a certain shape. If you can find a pre fab which is the shape you want for that patient then fantastic, use it. If, however, you find yourself comprimising what you want, what shape you think will work best, because the pre fab is not that shape, then you should probably consider custom.

    Much as tayloring. If you are 5ft 11 inches tall with a 34 inch waist and a 31 inch leg there is not a great deal of point buying a made to measure suit, it will be a similar size and shape to the suit you buy from marks and spencers for a fraction of the cost. Of course the taylored suit will be a PERFECT fit, and will be exactly the colour and material you want, and will be better quality, but the off the peg will still do the job. If, however, you are 5ft 2 inches tall but with a 36 inch leg and a 44 inch waist the off the pegs will not work for you. You need custom.

    Not really. But then lack of evidence is not evidence of lack! And there is no evidence to say taylored suits look better and last longer than a suit from primark either.

    You can steal that analogy if you like.

    Regards
    Robert
     
  5. markleigh

    markleigh Active Member

    Firstly, I don't put thanks at the bottom of everyones post for the sake of it. I genuinely appreciate people giving of their time when responding. Which OTC devices do you favour & how do you set your price? Do you use different types for different cases or one type & adjust accordingly?
     
  6. Thankyou sir:drinks

    Got it first guess.

    Its easy to forget when we refer to pre fabs collectively that there is a HUGE range and choice and that they are all very, very different. Some are wide, others narrow. Some rigid, some cushioned. Some have big lateral arches, some have virually none. to continue our tayloring analogy, the more choice you have "in store" the more chance you have to fit sir to sirs exacting requirements. And with a little skill at modifying you can accomodate even more feet.

    My advice would be to have a selection which you are familier with. you can keep stock if your cashflow can take it (certainly of the cheaper ones) and order the more expensive ones in when the patients demand. Its good to be able to show the patient what they are getting though so maybe keep one or two of each.

    The customs I use are these. To be extra nice I've linked to them so you can see purdy pictures.

    Freelans - they are very very cheap and with some felt and a heat gun you can do a lot with them With some poron, some pre fab components and a grinder you can do more still!

    http://www.algeos.com/acatalog/Algeos_Product_Range_Moulded_EVA_Insoles_517.html

    Slimflex + - As the name suggests these are pretty good for the slim shoes where a freelan is very wide (mind you its easy enough to trim a freelan). Also very cheap but a lot more guts than the freelan. I find them less easy to modify though

    http://www.algeos.com/acatalog/Slimflex_PLUS.html

    Both of these need a fair bit of pimping before they become a serious device but are less than the cost of a happy meal at Mc Donalds.

    Duosoft - These are great for those high risk feet where you want a bit of cushioning or deflection. Easy to grind a cavity out for pressure peaks with a standard clinic drill (with the right burr). Ver' squashy. Patients love em

    http://www.algeos.com/acatalog/Duosoft_PLUS.html

    Interpod modulars - At the pricey end of the spectrum but I love these. The choice of "clip" is good an I like the huge great 1st met cutout. And it is a HUGE 1st met cutout BTW. With a grinder there is not much you can't do with one of these.

    http://www.algeos.com/acatalog/Interpod_Modular.html

    Interpod soft - Used to use a lot of these, they're very deep so you can grind underneath and get all sorts of shapes. However I've more or less switched to the modulars and duosofts. These are a sort of half way house between the two.

    http://www.algeos.com/acatalog/Soft__Full_Length___Moderate_Arch__6__.html

    Globotech comfort - Rarely use these, but if you want a really thin insole for a really stupid shoe they'r pretty good. Also pretty pretty (they look nice). Lets face it you can choose an orthotic based on shape, density, prescription, stiffness or whetever, the first thing they do is stroke it and see if it feels nice. These are lined in genuine kitten skin.

    http://www.algeos.com/acatalog/Globotec_Comfort_-_3_4_length_.html

    This covers me for most of what I need. Different strokes for different folks of course. There are lots of other choices, some of which i've tried and not liked, others I've not tried yet. The new slimflex kinetic looks interesting to me. But the best pre fab is the one you get on well with!

    Pricing wise, it depends on the pre fab. I generally do the really cheap ones for 20 - 30 and the posh ones for about 50 -60. But thats up to you.

    Cheers
    Robert
     
  7. Bill Bird

    Bill Bird Active Member

    Hi Robert

    Can a carefully designed bespoke shoe, where the insole is shaped to be the same as a custom device would be, and where the posting is built into the heel and into the sole at the ball joint, act as a functional orthotic?

    I first studied biomechanics with the London Post-Graduate Study Group under Ray Anthony in 1979. I asked him the same question then. He thought about it for a minute and then said no; that a functional orthotic acted as if it was part of the foot within the shoe, changing angle as the gait progressed and a shoe couldn't do that.

    So much has progressed in biomechanics and orthotic design since then. Are Ray's comments then still regarded as true now? http://www.podiatry-arena.com/images/smilies/17035.gif

    Bill Bird
     
  8. Depends on your definition of a "functional orthotic". What can be said is that a foot orthosis provides a means of manipulating the reaction forces at the foot's interface with the device; the reaction forces can also be manipulated at the foots interface with a shoe without an orthosis by manipulating the shoes geometry and physical characteristics.
     
  9. As Simon says it depends on how you define Functional foot orthotic. I've always had a bit of an issue with that as a descriptive term because by the strictest dictionary definition almost ANYTHING you put in shoe will alter function to some degree and therefore even the humblest heel raise could be described as an FFO.

    However I note you said "act as" not "be defined as" so I guess you're after a practical answer rather than a lesson in semantics. In which case I would answer Yes.

    As Simon stated one has to consider at least 5, occasionally 6 interfaces between the skeletal structure of the foot and the ground. There can be "slop" at any one of these interfaces. You stated that the insole of the shoe, the dorsal surface, is the same as the FFO. Between the dorsal surface of the insole and the ground there are generally only two interfaces, between the inferior / bottom side of the orthotic and the inside of the shoe and between the shoe and the ground. With an FFO and a normal shoe the posting is on the FFO. In your example the posting is on the shoe. Will it change what happens above it? I seriously doubt it.

    Put another way, imagine an FFO which has been made neutral but upon which a 5 degree extrinsic post will be fitted. If you hold the shoe, the insole and the wedge in your hand, does it matter if you stick the wedge on the inside of the shoe, or in the same position on the bottom of the insole? Probably not.

    Put yet another way, if you put the wedge on the FFO, making it a properly posted FFO, then put superglue on the bottom of the FFO before you put it in the shoe so the wedge was adhered to both the insole and the shoe, would it change the function? would it cease to "act as a FFO" just because the wedge was on the shoe AS WELL as the insole?

    Thats just my 0.02$
     
  10. And it could be argued that you have made the effect of the device greater by removing one of the points of movement by glueing the device to the shoe. There will be no or much less device - shoe interface movement.

    Bill Add another to the yes but.... column if you want.
     
  11. Bill Bird

    Bill Bird Active Member

    Thanks Simon, Robert and Michael. I appreciate your thinking.

    To me a functional device would be one that is rigid and has prescription posting which differs from heel strike to mid-stance to propulsion. If a shoe were to do this, it would rock whilst sitting on a flat surface. I have done this but it would have to be a very strong shoe to keep that shape when a 220kg man is standing in it. It would have to be a carbon fibre insole!

    A related question has to do with ethics. It often happens that a patient comes to me with a prescription orthotic which is too bulky for an off-the-shelf shoe. I'm asked to make bespoke footwear which accomodates the foot and the orthotic, creating the ideal environment for the orthotic to work. This can be anything from a solid flat insole to support the posting, to a wide heel base so that the ground reaction forces can reach the foot in the right way via the orthotic. That's a discussion in it's own right as there is a wide range of elements that make a shoe support an orthotic. Anyway, fair enough, that's a good working relationship between the Pod and the Shoemaker.

    Where it gets fuzzy is when the pnt asks me to make the shoe do the same thing as the orthotic without having to put the device in. What they are asking for is what we discussed above. I always say that a rigid device that has prescription angles ground either intrinsically or extrinsically, that is put in a shoe that supports it is the best solution but that a simple foot bed can be done as part of the shoe.

    The problem for me comes when the pnt is keen to drop the orthotics and just have the shoe. If I go ahead, I'm doing what the pnt asks but I'm losing the valuable relationship with the Pod. If I don't, I keep the relationship with the Pod but the pnt isn't happy.

    I think the ideal would be to be able to form a relationship with the Pod similar to the one between an orthotic manufacturer such as Langer and the Pod. Can you see that working?

    Bill Bird
     
  12. Bill, if I can get a patient to wear an off the shelf shoe that will achieve the goal of decreasing the patients symptoms equally as well as could be achieved with an orthosis + shoe combination, I will go for the shoe in isolation every day of the week. Custom shoes are frequently expensive and often don't meet the cosmetic requirements of the patient, so an orthosis within the patients footwear is the way to go in these cases. Sometimes both footwear modifications and orthosis in combination are necessary. Horses for course.
     
  13. markleigh

    markleigh Active Member

    Hi Robert. I purchased a couple of the Interpod Modular devices - they look neat but the attachment pieces (same densities but 3 different arch heights) seem to be too soft. I'll experiment with them & see what patients think. Have seen a lab here in Aus (TOL), have a range called CFA devices which also look neat & very adjustable but made out of polyprop.

    Mark

    Got it first guess.

    Its easy to forget when we refer to pre fabs collectively that there is a HUGE range and choice and that they are all very, very different. Some are wide, others narrow. Some rigid, some cushioned. Some have big lateral arches, some have virually none. to continue our tayloring analogy, the more choice you have "in store" the more chance you have to fit sir to sirs exacting requirements. And with a little skill at modifying you can accomodate even more feet.

    My advice would be to have a selection which you are familier with. you can keep stock if your cashflow can take it (certainly of the cheaper ones) and order the more expensive ones in when the patients demand. Its good to be able to show the patient what they are getting though so maybe keep one or two of each.

    The customs I use are these. To be extra nice I've linked to them so you can see purdy pictures.

    Freelans - they are very very cheap and with some felt and a heat gun you can do a lot with them With some poron, some pre fab components and a grinder you can do more still!

    http://www.algeos.com/acatalog/Algeos_Product_Range_Moulded_EVA_Insoles_517.html

    Slimflex + - As the name suggests these are pretty good for the slim shoes where a freelan is very wide (mind you its easy enough to trim a freelan). Also very cheap but a lot more guts than the freelan. I find them less easy to modify though

    http://www.algeos.com/acatalog/Slimflex_PLUS.html

    Both of these need a fair bit of pimping before they become a serious device but are less than the cost of a happy meal at Mc Donalds.

    Duosoft - These are great for those high risk feet where you want a bit of cushioning or deflection. Easy to grind a cavity out for pressure peaks with a standard clinic drill (with the right burr). Ver' squashy. Patients love em

    http://www.algeos.com/acatalog/Duosoft_PLUS.html

    Interpod modulars - At the pricey end of the spectrum but I love these. The choice of "clip" is good an I like the huge great 1st met cutout. And it is a HUGE 1st met cutout BTW. With a grinder there is not much you can't do with one of these.

    http://www.algeos.com/acatalog/Interpod_Modular.html

    Interpod soft - Used to use a lot of these, they're very deep so you can grind underneath and get all sorts of shapes. However I've more or less switched to the modulars and duosofts. These are a sort of half way house between the two.

    http://www.algeos.com/acatalog/Soft__Full_Length___Moderate_Arch__6__.html

    Globotech comfort - Rarely use these, but if you want a really thin insole for a really stupid shoe they'r pretty good. Also pretty pretty (they look nice). Lets face it you can choose an orthotic based on shape, density, prescription, stiffness or whetever, the first thing they do is stroke it and see if it feels nice. These are lined in genuine kitten skin.

    http://www.algeos.com/acatalog/Globotec_Comfort_-_3_4_length_.html

    This covers me for most of what I need. Different strokes for different folks of course. There are lots of other choices, some of which i've tried and not liked, others I've not tried yet. The new slimflex kinetic looks interesting to me. But the best pre fab is the one you get on well with!

    Pricing wise, it depends on the pre fab. I generally do the really cheap ones for 20 - 30 and the posh ones for about 50 -60. But thats up to you.

    Cheers
    Robert[/QUOTE]
     
  14. markleigh

    markleigh Active Member

    I apologise because I've obviously formatted my message badly & have put my comments above Roberts thoughts - just confuses things.
     
  15. Bill Bird

    Bill Bird Active Member

    I couldn't agree more Simon. There's a small percentage of people, however, for whom nothing else works but made to measure because they're feet are so unusual. I've been running an option at De Montfort University in their BA in footwear design, on bespoke orthopaedic footwear design. They are working with aesthetic appearance rather than functionality but the orthopaedic function has to be there. You'd be surprised at how attractive some of their designs are for feet with bunions, hammer toes and pes plano valgus. This is the third year we've run it and next years intake is 36 students.

    Bill
     
  16. robby

    robby Active Member

    Regarding using footwear to act as functionally active device rather than using orthoses inside a shoe, Rammi Aboudd, wrote a paper a couple of year ago suggesting exactly this.



    Watch this space regarding biomechanically functional shoes.

    under development and testing at this moment aimed at functionally altering the gait in a particular group of diabetic patients. The Langer Helix Shoe.

    test have proven extremely interesting with a 40%+ drop in force time curves, reducing loading over the at risk forefoot, in suitable patients. when compared to standard Diabetic prescribed footwear.

    Further information is available !
     
  17. webthotics

    webthotics Member

    Hi, short history of myself,
    i have been an orthotics technician at the local hospital for 20 years and have had my own orthotics lab for about 15 years, i managed to persuade our senior podiatrist at the hospital to purchase mass produced shells about 6 years ago. i can produce about 1 pair every 45 minutes in comparison to 1 pair of bespoked every 3 hours, so extremly cost effective. They are very versatile and you would be surprised at what you can do with them, we now very rarely cast anyone.
    We are seeing on average 120 patients per month and during the 6 years we have done some reviews and virtually all the patients are very happy with the orthotics and have helped there problems. On the private side i manufacture orthotics of various materials, about a third are mass produced shells, i have yet to have one returned,

    Cheers,
    Mark
     
Loading...

Share This Page