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I have always been taught that when casting, to plantarflex the first ray to get the best orthotic outcome. When the plantarflexing of the ray is not possible, i.e. forefoot varus that you can post up to the deformity. When trying to reduce grf under the 1st way, you should add a reverse morton's extension or 1st ray cut-out. I work in an o and p lab among many certified orthotists. Whenever they see a severe pes planovalgus foot/pronated foot in either an adult or child, they immediately post/wedge under the 1st metatarsal. Isn't this increasing grf under the 1st and jamming the joint by dorsiflexing the 1st ray? My supervisor frequently does this in children, especially when they demonstrate hypotonic, down syndrome, a pronated foot, cp, etc. Can you do this? Thanks

Nic Vaughn C.Ped

 

Hey Nic

Yeah you're right it will block the 1st ray. Two things, most casts that you receive for orthotic manufacture probably have not had the forefoot maximally everted and the hallux dorsiflexed to reduce any supinatus or metatarsus primus elevatus. I also manufacture orthotics, when i started out every cast had a huge degree of forefoot varus now i have virtually none!

I would question the casting method if you are seeing many of your cast with an inverted forefoot angle. True footfoot varus as a structural osseous deformity is rare.

If you are going to post with a large degree of varus make sure you either apply a deep 1st ray fill, reduce the shell width medially to the 1st/2nd interspace or have a 1st met cut out. This way if it is a true forefoot varus you are correctly posting it but still allowing the 1st ray to plantarflex. I would however question the casting method.

In a developing foot the last thing you want to do is block movement in the 1st mpj.

Good luck!

Scott Shand