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Medial arch fill and 1st ray posting

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Nic31, Dec 6, 2005.

  1. Nic31

    Nic31 Welcome New Poster


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    Hello,

    I have experienced a few problems with casting materials, cast corrections and fit of the orthotic especially in the medial arch area. My last two patients have complained of too much push at the medial calcaneal tubercle area and no contact at the distal arch. I have been told that the sts sock(I use this almost exclusively) can have problems contouring to the foot and that has translated into a low arch countour in the cast. Am I correcting too much at the proximal arch area. What if you have an inverted cast from anywhere from 10-25 degrees where you you have to blend in the platform into the foot? How do you do this without compromising the 1st ray post? Thanks
     
  2. footdoctor

    footdoctor Active Member

    Hi,

    Heres a couple of suggestions.

    If the distal portion of the arch is not controlling the foot you may have either applied the bandage too tight around the toes creating a elevated 1st ray position or you maybe had a metatarsus primus elevatus or supinatus and failed to "push it out" Personally unless it is a fixed osseous forefoot varus I always plantarflex the 1st met/ray by applying a plantarward force to the dorsal aspect of the mpj. This will reduce any functional elevatus/supinatus that would give a shallower distal arch contour and subsequently less midtarsal control in late midstance.

    In regards to the pain felt at the proximal arch area,did you include a medial heel skive? Does the patient have a tight p/f band or inflamation at the site of the insertion of the p/f also did you include a rearfoot varus post? What degree? Does the stj excessively pronate? Did you use a deep heel cup?
    How much fill did you use proximally(usually very little) How long was your rearfoot post? What shell material did you use? what was the patients weight and condition?

    If you could answer these Nic,I'll try and help you out.

    Scott
     
  3. footdoctor

    footdoctor Active Member

    push that fake out!!

    Nic,

    I do understand your point regarding how to incorporate your forefoot balance platform in to the distal arch/1st ray.I am however a little concerned at the ff angle that you are having to balance! It is very unlikely that you would get 10-25 degrees of true forefoot invertus.If you are new to the orthotic manufacturing game then I totally understand cos 70% of my casts used to have massively inverted forefoot deformities,now none of them do!

    When you do you biomech see if you can reduce the forefoot angle by plantarflexing the mpj or dorsiflexing the hallux,if this reduces the angle,chances are you have a supinatus which you should reduce when casting.It would be very difficult for a patient to tolerate an orthotic device that has been posted 25 degrees in the forefoot anyway,that is if they could get their foot inside the shoe!

    I suggest that if the forefoot angle is a large degree of forefoot varus (over 8 degrees) that you section the cast to reduce the angle.

    When you blend in your plaster fill from plaster platform to arch do so sparingly.But also bare inmind that too little plaster under the 1st ray may result in dorsiflexing the 1st ray and jamming the whole thing up.

    With your next few patients try and remove the huge varus angle.I dont think you'll have this problem again.

    Regards

    scott
     
  4. Craig Payne

    Craig Payne Moderator

    Articles:
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    nic31 - you may need to explain a bit further - thre is a huge variation in terminology used for this.
    If i understand this correctly, then something is very very wrong. A forefoot varus is extremely rare and I almost never use a forefoot varus post (a couple of exceptions have recently found there way into my prescribing).
    Also gone away from doing anything more than just very minimal plaster additions ... as someone said to me recently - "sick of having a party to invite the foot down to the orthotic due to all the plaster added by the lab" ... there will be lot more heard (I and a lot of other have been talking more about it) about the need for conformity with flexibility of the arch profile of the orthotic to the arch.of the foot.
     
  5. PF 3

    PF 3 Active Member

    A supinatus would also take some time to reduce immediately after the rearfoot has been corrected?

    Is the highest point of the medial arch of the orthotic too far distal and blocking 1st ray plantar flexion. Easy cast error to make with blake inverted devices.
     
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