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Foot orthoses/trainer compliance

Discussion in 'Biomechanics, Sports and Foot orthoses' started by RobinP, Apr 14, 2010.

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  1. RobinP

    RobinP Well-Known Member


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    Dear All,

    Once again, I am seeking the collective wisdom of the Arena.

    Although the history of this patient is obviously important, in this instance, I am looking for slightly more practical help.

    The primary issue is slipping of the heel inside trainers as a result of foot orthoses with equinous raise.

    The prescription for this patient is functional foot orthoses with medial rear foot posting and medial heel skives. There is also 9mm heel raises bilaterally to accommmodate bilateral midfoot equinous.

    The presenting complaint for the patient is resolved by the orthoses but she is a keen runner and finds that her running is hampered by the heels slipping out of the shoes. I have tried reducing the heel raise but when she performs the lunge test, she is unable to reach the arbitrary 38 degrees and when she walks, she does not get the same relief from the pain.

    I have tried changing her lacing pattern and height which helps but does not resolve the slipping. Padding the underside of the tongue doesn't help as the angulation of the dorsum of the foot is too vertical for the force applied by the laces to pull the foot back into the shoe

    I have suggested to her that a different trainer, such as a Nike might be better as they have a slightly higher heel/sole differential(?) but she is vary brand and style loyal to Asics.

    As I write this, I am kind of answering my own question, I feel, but does anyone have any pearls of wisdom to stop heels slipping in the shoes? I suppose I am thinking along the lines of.... whether any particular model of Asics had a particularly high heel counter, that type of thing.

    All suggestions gratefully received

    Thanks

    Robin
     
  2. Robin get the heel lift built into her shoes if she is always going to have the lift the same height when running.

    Get a shoe person to remove the upper from the sole add in the height, length and angle of the raise you want glue down the upper again, put in your device ,
    go running. When she replaces the shoe off to the shoe maker before she runs in them. It only gets complicated if you want to change the height of the raise.

    Hope that helps.
     
  3. RobinP

    RobinP Well-Known Member

    I have seen the same article on another thread and that was the first thing we tried which helped, but not completely.

    Heel grips could be an option. My experiences with them have not been positive as the donning and doffing process often takes the heel grip with it. In saying that, I could have it stitched into place.

    Thanks for your input

    Robin
     
  4. RobinP

    RobinP Well-Known Member

    I did wonder about doing this as I do it quite a lot for post THR shortenings or for AFO tuning of GRV. However, I have only ever done it wherby, the EVA is split and the raise sandwiched in then restuck. As effective as this is, I have found it doesn't stand up to much punishment.

    But, if what I think you are saying is correct, the upper can be detached from the sole unit altogether and the raise added before resticking? I have never had it done before but is it robust enough and how much does it affect cosmesis(not that it is of great importance admittedely)

    Thanks

    Robin
     
  5. Before Kevin and or Simon get upset with the abbreviations (wish I could spell)

    what is
    THR ?

    AFO = ankle foot orthotic ?

    GRV ?
     
  6. Griff

    Griff Moderator

    THR = Total hip replacement
    GRV = Ground reaction vector??
     
  7. RobinP

    RobinP Well-Known Member

    Yes, apologies for that. I'm trying to cut down my time on Podiatry Arena to concentrate on trivial things like work and earning money and I got a little carried away

    THR - Total Hip Replacement
    GRV - Ground Reaction Vector
    AFO - Ankle Foot Orthosis

    Robin
     
  8. CraigT

    CraigT Well-Known Member

    You may have done this , but I would be looking at making the orthosis as minimal as possible.
    Is the orthosis padded? If so, try it with no padding.
    I personally think that padding on an orthosis is over-rated in its importance.
    What you are saying is that the most important thing is the lift and correction- often orthoses are made with this and in addition they have a 3mm cushioned cover. Get rid of the cover and you will get some space back.
    As I said though, you may have done this already...
    You say there is less symptom relief with less lift when walking- is it the same running?
     
  9. RobinP

    RobinP Well-Known Member

    Hi Craig,

    The cover is 1.5mm thick so I guess I could look to get a little space back from that. I agree with you about covers being over rated but in this instance I was trying to change the "feel" for the patient as little as possible with comparison to her existing trainer set up.

    With regards to the pain relief when running with a lowered heel raise, I must confess that I did not try. I suppose my reasoning was that, if I was raising the heel to accommodate midfoot equinous and basing, in part, the height of the raise on getting a reasonable angle(of the shank angle to the vertical) on a lunge test, then lowering the raise would be more likely to be problematic in the running situation where increased dorsiflexion at the ankle may be required.

    I'm not sure if my reasoning is sound but given that there are so many other limiting factors, there does not seem to be any reason not to try it.

    Thanks
     
  10. Boots n all

    Boots n all Well-Known Member

    You said you have tried external heel raise and it has not lasted well, then whoever did it ask them to use a higher density EVA next time.

    Heel slip, the next thing we look for is the orthosis the same width as the insole pattern of the shoe, not the soft removable foot bed but the actual insole itself, if not this means the upper is held away from the foot by the orthosis, its not just the topline of the shoe that holds the heel in place.

    To check this place the orthosis in the shoe, forward from the heel by about 3cm, then slowly push the orthosis back to the correct position watching to see if the topline of the upper moves at all, focus on the area of where the Maleolus would sit, it should not move at all.

    Does the orthosis have a lateral edge that comes up to stop the foot moving off in the lateral direction itself, if not this will push the lateral heel hard against the upper and the medial part of the foot away from the upper= heel slip.

    If all of these are okay, get the upper extended 2cm up, this increases the back height and the lugs for lacing, be sure the pitch of the extension is correct or nothing will be gained
     
  11. RobinP

    RobinP Well-Known Member

    Hi David, i was hoping you would come in on this.

    I hope some other folks reading this post learn a litte from the information you have just posted. It took me a long time to figure out some of the things you mention in this

    Sorry, i probably didn't make it clear. The bonding agent used never seemed to be sufficient to keep the concealed raise in place and the raise kept coming apart, especially quickly in wet conditions

    I was quite careful about this when I fitted them although I have not done your specific test. Salts in the UK manufactured the orthoses and they have a library of the insole profiles and their dimensions so it was quite accurate. I have had that trouble many times before realising what the problem was, so am well aware of it.

    The heel seat depth is 13mm which is not very deep but should be sufficient to prevent lateral translation of the heel against the outside quarter in this patient as the amount of correction is not terribly aggressive. If I took the heel seat depth much higher, i would have risked the heel width of the orthosis being too wide and deforming the heel counter as you mentioned earlier

    This seems promising. How do i extend the upper?

    Many thanks

    Robin
     
  12. Boots n all

    Boots n all Well-Known Member

    l cant tell you everything robin:D

    A picture is worth a thousand words....
    l am working on one currently for a talk l am about to give, when l finish it l will put a picture up on my website of the modified boot for you to see.
    l will post a link up once it's done
     
  13. RobinP

    RobinP Well-Known Member

    I look forward to the post. If it makes any difference, i have no desire to do the adaptation myself(I have neither the skills, nor the understanding), I just don't really understand how the counter/upper height of a trainer can be raised. Surely, there is a finite amount of material to work with. Also, it would mean replacing the heel stiffener with something higher.

    If you think it would be appropriate, I would gladly ship something to australia for you to make the adaptation

    Regards,

    Robin
     
    Last edited: Apr 15, 2010
  14. Boots n all

    Boots n all Well-Known Member

    LOL, Not worried about you doing the job, if l thought that way l would not share my thoughts with you.

    Hope to have it done before end of this week...or l am in trouble with others..........:hammer:
     
  15. Robin, too narrow a heel cup will prevent fat pad expansion and lift the heel higher in the shoe. Try reducing the heel cup height or try re-casting and adding more lateral expansion.
     
  16. RobinP

    RobinP Well-Known Member

    Simon,

    Thanks for the suggestion. If I add more lateral expansion, I am going to cause heel counter deformity and gaping at the quarters.

    Lowering the heel seat may be a solution. I am concerned that lowering the heel seat may allow too much lateral translation of the foot on top of the orthosis as a result of the medial heel skive and negate it's effectiveness. Am I right to be concerned?

    Robin
     
  17. Gaping at the quarters is not a problem I have encountered when using correct lacing. Robin, there is only one way to find the answers to your questions on lowering the heel cup height (I presume that is what you mean by heel seat), but if you've got a heel stiffener in the shoe, that is going to stop much of the sliding.
     
  18. Boots n all

    Boots n all Well-Known Member

    If its like any of the runners l have seen it is going to be force lasted, so the strength of the heel stiffener is comprised by the fact that it does not go under the insole, it has no real foundations.

    In fact, most force lasted products the heel stiffener stops 1-2mm before the insole, never touching the feather edge, the only thing supporting the heel stiffener is the upper and the sole if it comes up far enough.

    Look to see that the sole material comes up the side of the shoe, above the the level of the insole, you want about 10mm high and about 8mm wide for it to make up for the lack of traditional foundation the heel stiffener has not got in the force lasted product.

    l have attached a picture from a presentation l gave recently, the left, a runner is a common runner that is force lasted, the heel stiffener is colored red, you can see it does not come down to the insole and you can also see when the back portion is removed that the sides of the runner have opened up like a vases as the top line was the only thing holding the shape. compare this to the shoe on the right where the heel stiffener goes under the insole retains its shape, it has a foundation.

    This is why you need the sole to come up the side of the runner
     

    Attached Files:

    Last edited: Apr 15, 2010
  19. Boots n all

    Boots n all Well-Known Member

  20. RobinP

    RobinP Well-Known Member

    David

    Thanks for the link.It took me a while to realise what had actually been done to the boot. The modification is very well presented. I understand now what you meant by raising the upper height. I thought you would detach the sole unit and pull up the feathered edge by an amount,replace with a higher stiffener through the bottom and then reattach.

    I didn't realise the modification was being made to the quarters by extending beyond the padded collars. Clever and,as I said, neatly done.

    I know you don't want to use specific brands, but could you PM me the brand of runners with the heel counter running under the heel as in the 2nd image please?

    Simon

    I think you are right, I may just have to bite the bullet and make the modification.


    I intend to see this patient either today or tomorrow. I think the plan of action will be

    1. Lower the heel raise and test in running. If symptoms stay relieved, make raises to stick in her walking shoes only.

    2. Lower the heel cup height to allow greater fat pad expansion.

    3. Speak to the patient about modifying the runner externally (raise the heel by sandwiching in some EVA) or internally(raising the quarter and counter heights)

    I don't really want to have to adapt her runners as it will involve doing the same to all of her runners in the future. However, it may have to be the case.

    I will let you know how I get on.

    Many thanks to all for your suggestions

    Robin
     
  21. Boots n all

    Boots n all Well-Known Member

    Thank you, we do make every effort to make any mods look they didnt happen, very hard with some products.

    Detaching the upper from the sole would not work as it is force lasted, the upper does not go under the insole.

    The boots at the top of that page had the sole detached, wedge insert and reattached

    The image of the counter running under the insole (board/cement lasted) is not a runner rather a shoe, a school shoe that we make here down under, By "Bilby";)
     
  22. RobinP

    RobinP Well-Known Member

    Hence the reason you put this in an earlier post - sorry being really slow!

    Robin
     
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