Which pre-forms are good and which are bad?

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OK ya'll last thread from me for 2008.

I should like to know which pre-forms you prescribe and why? Do you use specific brands/ types for specific conditions/ patient groups; is it about cost, adaptability, fit etc.? Which ones wouldn't you touch with a barge-pole and why? What are the strengths and weaknesses of each design.

For example, I use the Vasyli Dananberg because I like it's Kinetic wedge, however it's rubbish for grinding and eva wedging doesn't adhere well to it, particularly at the rearfoot. This is mainly because of the slits around the heel cup. It's not that cheap relatively speaking but I've not had any problems with shoe fit. What other attributes haven't I discussed here that are important?

 

Simon,

I am always looking for new prefabs to experiment with and have had some success with Powersteps, Vasyli and Superfeet.

For PF patients the Powersteps are my first choice and they hold up fairly well, somewhat heat modifiable and grindable. I have found that modification such as medial arch adjustment is not possible with the Superfeet and Vasily due to the materials and grinding you covered; forget it!. Both the Powerstep and the Superfeet have a moderate heel cup and decent support for a prefab

The JSB looks like a good inexpensive prefab that I just recently came across but I haven't had occasion to tinker with them just yet. Down Unders is another that I am investigating, maybe some one can chime in who has knowledge of these.

An entire box full of Vasyli prefabs of various designs was left in my office for me to play with by a shoe rep who attended the seminar. I do not find that heat molding accomplishes much of anything to be honest (sorry Howard) but the 1st ray plug and various wedge add-ons are intriguing and genius in their simplicity. Being I acquired these for free I have not charged a patient for them so I have no idea their cost but probably sub $50 for them and sub $100 for the Dananberg.

I do wish the Danenberg was of a slightly more dense material because of the prefabs it is the most stock modifiable device and the only one to address 1st ray function. I also with the heel cup in the Dananberg was slightly deeper.

If I have to alter, modify or reheat a device much in my office it and it becomes more than a simple adjustment, I feel that this warrants a more durable and customized device. I prescribe the next step up which falls into the semi-custom category with a price point somewhere between a prefab and a custom. This is usually about $200/pr. I have also found that prefabs universally decrease in their effectiveness due to an inherent loss of structural integrity much sooner than our beloved customs (well duh!)

For these semi-custom or modified devices I use pre-cut blanks of Carboplast or pre-shaped DBX6 (I have also found these materials incredible for low volume applications such as cycling shoes and ski boots and they are durable). If you have never used Northwest's DBX6 I recommended it, highly modifiable and inexpensive compared to a true custom from an outside lab. Both of these materials give me a flexibility and ease to work with adding accommodations when not choosing a custom for a patient.

For these reasons I usually use prefabs as temporary inserts for minor acute complaints and where the modifications are very minimal and a custom is not warranted. Say acute PF, traumatic heel pain or fat pad loss etc. where they just need a small measure of help to recover. I never base my devices on the perception of what the patient can afford but on the pathology and medical necessity of the orthosis.

 

We currently use 3 to give us a good cover of different shapes and design parameters:
1. Formthotics
2. Interpod Flex
3. Prothotics (the Australian; not USA version)

 

I think there are 2 elements to consider with a pre form

1. How easy it is to modify

2. How suited for purpose it is in its present form.

In my primary clinic i use few pre fabs beyond the occasional pressure releif device. However i also do surgery clinic where i have little access to my lab so i use lots there.

I use:-

Freelans:-

Fairly gutless as are but ever so easy to modify with semi compressed felt or some pre fab component

Duomed

This is a double (low over high) density eva shank dependant. Takes a 1st met head cutout or a neuroma mod rather well. However what i like about these is that i can get them to almost any shape with judicious use of a heat gun. Cavities, , sus tali supports and even a pretty good analogue of a kirby skive can be acheived. Once the superior surface is to my liking i then backfill the voids i have created with scf. Thus the device stays shank dependant. If it goes well i can easily do a proper backfill job with eva or poron and grind the inferior surface flush.

Happy new year

Robert

 

We use 1) interpod flex, due to low bulk profile, 3 choices of degrees correction and durability.
2)prothotics from TOL.

 

I personally use a variety; powerstep, orthofit, talar made, dananberg, vasylli. the determining factor is if it fits into the shoe as well as supporting or realigning the foot in the right places. They can be modified with felt or poron but at the end of the day they need to be 'wearable' and 'bearable'.

Otherwise it's footprints orthotics, which wouldn't be that much more in price for a 'customised' fit.

Happy New Year to all.

Caroline.

 

G'day all,

I currently use a pre-form called e-thotics produced by elite orthotics lab in Brisbane Australia (No business or financial link!).

I find them excellent for grinding and finishing. EVA adheres very well and you can grind into the shell quite a bit (grinding bulk down at 1st ray and adding a 2-5 pmp and 2mm lunasoft cover etc).

I have several elite athletes from a variety of sports including ironman triathlon in these "customised pre-forms" and find they function fine for 1-2 years with a cover change if need be. They only come in full length version (2 densities) so a shoe/football boot etc with removable insole is a must.

On a different note, recently I had a marathon runner with MTSS who was pronating throughout midstance and late into propulsion on the threadmill. His neutral shoes were collapsing medially.

I put an ethotic straight off the shelf( ie no reafoot posting or cover etc) in the shoe to show him what a more supportive shoe might feel like and the foot assumed a far more neutral alignment on motion analysis.

Is this an example of a change in neural or proprioceptive input with a subsequent alteration of muscle tuning to bring about a preferred movement pattern? Mechanically there is no way the insole could have corrected the foot position so markedly without any modifications. It does however have a rough top surface.

All The Best,
Athol Thomson

 

I used to use Vectorthotics, which were quite handy in treating each foot individually with respect to the the degree of varus rearfoot post you required (i.e. what 'lego' piece you attached). However I found from my point of view the addition of a forefoot post was some what of a ball-ache, and also it was difficult to add a heel raise to one/both devices due to the extrinsic clip on post. Also the top cover supplied has next to no cushioning. From the patients point of view I also had one or two who found them a bit uncomfortable (most commonly reported issue was heel pinching) and fit into anything other than a trainer or roomy work shoe was a challenge.

I more recently switched to Interpod Flex and so far had no problems with shoe fit, or patient comfort. For me they are very reasonably priced for the device you are getting, easily modified if need be (additions of EVA heel raises for example) and the patients seem to like they way they look.

 

I have a powerpoint slide I use that is an animated collection of all the pre-form/pre-fab orthotic advertisments that I could find. It intrigues me how many there are and how many claim to be the best - how can they all be the best?

Orthotic prescribing is all about matching the characteristics of the foot, the needs of the foot and the restraints of the environment (eg activity and footwear) to the design parameters of the foot orthoses.

Who cares if its pre-forms or custom made or what method of negative model production was used or what type of pre-fab was used or etc etc, as long as the design parameters match what is needed?

The only problem I have is with those who only do it one way or use one brand of pre-fab

(BTW, if I sound as though I am in a bad mood, its because I am back to work tomorrow after my long service leave! :bang: )

 

Yes Craig I have to agree, I have said this several times but it appears falls on deaf ears. It’s the prescription that matches the patient’s needs as best as is possible that is bespoke and not just the custom matching of foot shape from casting. Personally I have tried many and still use a variety of brands but when it comes to prefabs / OTC I always tend to gravitate back to Vasyli but like Simon, I like Dananberg’s but don't understand why they are Teflon coated to make adhering wedges and posts difficult. I like the look of the ICB Dual density EVA from DLT but haven't tried them yet.

I don't think there really are bad orthoses just bad choice of orthosis for your patient. Anything might be the right choice for a particular patient.

I tend to only prescribe OTC's where the foot has only small excursions outside of what we would classify as normal. EG not too cavus not too planus not too much forefoot to rearfoot alignment deviation, not requiring too much posting or specialist posting like skives. Often the problem only requires mild facilitation of saggital plane progression, a Dananberg with a heel lift plus an ankle mob does the job perfectly, for a reasonable price, which is often an issue ie about £85 as opposed to £260. A bespoke orthosis would do the job just as well and do it longer because they last much longer and perhaps look more sexy and fit in lower volume shoes etc but it will not necessarily do the job any better in terms of pain relief. That’s often the customer’s choice and so that OTC script becomes the best for them.

I tend not to do favours though, i.e. make a pair of OTC fit the prescription, whatever it may be, just because they are cheaper and that is what the customer wants. This only leads to trouble and comebacks when they fall apart, don’t fit any shoes, cause rubbing, aren’t good enough etc, etc.

I find that most OTC do not have a wide enough or flat heel on the plantar surface (shoe orthosis interface) and so without a press it is difficult to fix a post or if the heel is not wide enough the post are ineffective because of the short moment arm relative to the frontal plane STJ axis.

Power step are my second favourite because they are quite stiff material they are also quite thin but being quite rigid they need to fit the foot shape quite well. Superfeet are good for narrow feet but don’t accept rearfoot postings very well.
Dananbergs come out on top for the quick turn around fit. As long as you agree that saggital plane progression facilitation is important and relevant in a great majority of cases.

Freelans and 1st phase are ok for temps but don’t really last long unless you have a good workshop to reinforce and glue them up. Having said that, in the past I have had excellent results with temps and the customer just renews them regularly.
Like I said I generally agree with Craig’s sentiments but even so I like to fit bespoke / custom most of the time because an orthosis can’t be too good even if it is too expensive. Although sometimes I think a customer will expect more from an expensive orthosis. So they will be extremely pleased and full of praise with a £40 orthosis that gives 50% relief but on the other hand, still be a bit disgruntled about a £300 orthosis that gave just 85% relief.


Some people just can’t afford custom
Some people just won’t afford custom
Some people just don’t need custom
Some people need nothing else but custom
Some people want nothing else but custom
Most can be reasonably catered for but
Some people must be shown the door

All the best Dave

 

Hi all,

At the clinic we currently use the P3 functional prefabricated polypropylene orthotic from ProLab US.

This device comes with or without a unitized rearfoot post with 4/4 correction,or 0/0, 2mm medial heel skive and 3 degrees of intrinsic forefoot valgus posting.

It can be buffed and modified. SCF can be adhered to the shell chairside or additions/coverings and extension can be made permanently using a neoprene based cement/adhesive.

The 4mm polypro shell is semi rigid and fairly hard wearing.

A durable,cost effective functional device when custom is out of the question!!

www.prolaborthotics.com for info.

Scott

 

I am gradually working my way through the various types of pre-forms: for myself - having a fairly staight forward case of STJ over pronation with no fore foot problems - I benefit from the Sole range. (yoursole.co.uk). I like these because they are heat moldable (just pop them in the oven for 2 mins). Plus they can be re-molded twice so they are cost effective. My walking boots are used on a daily basis and the orthotics have been in there well over a year) They only come in full length but have different thicknesses. I do supply and fit these for my patients, and, although there is a film showing people how to fit, I prefer to get the foot into that STN position so they're off to the best start. A good entry level insole.

Happy New Year to one and all

 

Itchyfeet

Is STJ 'over pronation' a symptom? Was this a diagnosis or just an observation? What was the problem caused by 'over pronation' that you wished to resolve?

Is STJ neutral position optimal and can you achieve the Kinematic changes you desire?

Just rhetorical questions as I think these topics have been discussed once or twice before.

All the best Dave

 

Yes,
I think itchy's using slightly different terminology to the rest of some of us. Probably you and I (Dave) would use scientific language like 'hyperpronation' to describe this terrible affliction. Once diagnosed, we could use a variety of different insoles, or 'orthotics' as some people call them, to alter their kinematics, or 'roll the foot out a bit', or we could even cure it with something like a hyprocure - http://www.gramedica.com/
:drinks

 

Bob

Well I kind of get what you mean Bob, if you define hyperpronation as that magnitude of pronation that causes pathology then that tautology is irrefutable.

However what I meant was that I would say that one should diagnose a symptom and then look for the cause, which in the case of sinus tarsi syndrome will be because of excessive compressive forces, which are caused by the joint surfaces closing together as the pronation of the STJ progresses. If the patient of interest has 15dgs of pronation it does not follow that all people with 15dgs of pronation will have sinus tarsi syndrome or high compressive joint forces and therefore 15dgs can be described as over or hyperpronation only in that person of interest.

Over pronation (whatever it is) is not a condition that requires fixing per se.

Cheers Dave

 

I use
Prothotics (From TOL): Standard for plantar fasciitis with a bit of poron under the heel. The Firm Wedge device is good for mild post tib dysfunction or Sever's if they also have significant rearfoot eversion.
Formthotics dual density for elderly/low pain threshold patients with OA/ RA pain/ achy old feet.
Vasyli/Dananbeg are good, but as a few others have pointed out, very hard to adjust/grind/glue to. We also had a batch where the 1st MTPJ plugs didn't adhere properly and slipped off, eventually sticking to the patient's dorsal 1st MTPJ (not where they're supposed to be). I use these for 1st ray, 1st MTPJ and plantar fascial problems.
I also use a lot of custom and semi-custom devices, and I agree with Craig, it doesn't HAVE to be custom to work!!
Beth.