Casting technique

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Any comments on this casting method and explanation of the function of the device?

 

He likes his "arches". Assuming that he's talking from a lay audience.

I've seen worse. Skip to about 4 mins. Apparently "what are called custom orthotics don't even try to raise the arch... this "orthotic" has no chance of supporting the arch correctly."

Feels like we're back in the 80s...

 

Ah God Robert not that, listening to him spew concern this early in the am makes me throw up just a little!

Yesterday I had a conversation with am ortho we haven't received a referral from in a while, I had called to inquire as to why. What I found out was they've been referring to a lab that in his words just has better pricing for their patients.

So I looked them up and found out they are an outfit that claims to be a podiatric lab but also provides orthotics on site. I called them and found out from the polite woman on the phone that they offer $200 "fully custom orthotics" to walk-ins, mind you about 1/2 the price of the low end of the market and considerably less than what most professionals charge or bill insurance. I suspect that they're merely matching shells to keep costs down and calling them "custom", there is no way a lab can be profitable selling them substantially below market to providers or at discount rates when dispensing to the public unless they're doing a boatload. She claims their "guru", quite well known in the industry mind you, is a Certified Orthotist.

Curious I Google him and nowhere does he show up on the web other than Facebook and LinkedIn where he lists no education but proclaims he is a CO...and this is where it gets tricky...he is a Chief Operating Officer of the lab...a CO get it? He's not listed on either professional credentialing body, both I was listed on in the past when I took Medicare for DME. More on this later, we are investigating to find out if he is indeed a Certified Orthotist.

I found this casting video on their website. I wonder how many of you would cast a foot with the ankle completely plantarflexed?

 

If labs can make money selling custom ortotics to professionals at $100 then they certainly should be able to make money selling the same custum device at $200. They don't even have to mail it back to the professional. There may be other issues like practicing medicine without a license. I have no idea about the legality of that. However, they should be abale to sell custom devices for $200 if they make them.

 

Not a bad technique to try IMO.

From seeing the video, I would guess the patient has equinus, decreased forefoot stiffness and a medially deviated STJ axis. Upon standing, the STJ is probably max pronated, the forefoot is DF relative to the rear foot and the MLA is collapsed. The PT tendon tensile force is increased as its working overtime to decrease the pronation moment and the floor of the sinus tarsi is getting slammed by the lateral process.

So, I think his thought process is to modify his NWB casting technique by placing the foot in an OKC supinated position as well as plantarfex the first metatarsal to increase the height of the MLA proximally at the level of the MTJ.

The supination resistance is probably very high but if the patient can tolerate the orthotic reaction force at the level of the TN joint, then the center of pressure will be shifted medially reducing the tendon tensile force within the PT tendon and plantar fascia as well as decreasing the intraosseous compression force within the sinus tarsi.

Add heel lifts to take tension off the Achilles and to reduce the time and magnitude of the GRF acting to DF the forefoot and he could be successful in his casting technique.

Now, you can also take a traditional plaster impression but I think you still want to keep the ankle slightly plantarflexed and let gravity bring the first metatarsal down or PF it directly or by DF the hallux to increase the MLA. Of course you can always pour the cast inverted to increase the arch height proximally to slow down the pronation velocity and add a 4 mm medial Kirby skive with a 14 mm heel cup.

Even if someone is misguided, I respect those that put thought into what they are trying to accomplish. I do not know this podiatrist but it appears he is having success nevertheless.

Steven

 

Once again, we are looking at a poster boy flexible, flexible FFT and doing some version of a foot type -specific cast without a foot typing.

This casting would be malpractice if it were performed on the rigid/rigid FFT.

Summarily, this is a safe, probably effective method of casting a flexible forefoot foot but since it is not diagnosed using functional foot typing, the doctor must play it safe leaving out many foot type-specific techniques of casting and prescribing which would be harmful to those feet that are nor the flexible forefoot FFT.

One casting technique for all, whether it be STJ neutral or this doctors version has too many built in problems.

Dennis

 

Eric I agree IF their "guru" is actually an orthotist.

Steven I also thought about the TN joint, hard to know what is going on with this patient from the video. He is either completely focused on the MLA (I believe you can achieve the same arch height with the ankle dorsiflexed and the Hallux dorsirflexed if that is your desire) and doesn't cast in the traditional position? My point was the lab in question presented this as the preferred method f casting.

Which leads me to Dennis. Finally we agree on something!

 

Yep.
There you go Dennis. I knew there had to be some things we agreed on