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Should FMT or a warm-up be used before casting

Discussion in 'Biomechanics, Sports and Foot orthoses' started by mike weber, Jan 10, 2010.

  1. Members do not see these Ads. Sign Up.
    In a thread started by Robert/Dennis there was a very small amount of discussion about what casting techniques people use.

    said thread

    Simon wrote

    This got me thinking ....

    Who warms up the foot before casting out a supinatus or other foot changes such as dorsiflexing the 1st ray , who uses Foot Mobs or Manipulations? and why do you?

    Ted may get excitied by this one
  2. TedJed

    TedJed Active Member

    HUH?!?:confused: Are you suggesting that pods will cast without mobilising first??? Really?:eek:

    This makes no physiological sense if our aim is to improve the functional capabilities of the body we are trying to help.

    Let me explain...

    E.g. For clarity's sake, let us have a hypothetical case of a plantarflexed 1st ray with no other influencing aetiological factors (I did say 'hypothetical'.)

    Remember the physiological law succinctly articulated by Videmann; 'Connective tissue always adapts to its shortest functional length.'

    Therefore, the plantar connective tissues (CT) under the 1st ray (1st m'sl:med.cuneif:navic) will adapt to there shortest functional length. I'm referring to the joint capsules, ligaments, tendons, plantar fascia and the related intrinsic muscles of the foot to name a few.

    If a cast is taken without effecting any change to these CT's, at best, the orthoses will maintain the contractures. Typically though, the patient will experience MLA discomfort as functional orthoses 'try' to elongate the 1st ray functionally. Tolerance will be an issue here because the means by which the 'stretching' tries to take place is inefficient, slow and uncomfortable.

    Our standard procedure is to provide 4-6 FMT sessions to release the CT restrictions over a 2-3 wk period combined with some prescribed home stretching, THEN cast.

    Would just 1 FMT session help? Sure, it would be better than none but a better long term cellular adaptation takes place with stretching over a period of time. It's like if you have tight hamstrings; stretching once can help but stretch consistently over a few weeks and the difference is more significant.

    I cannot see any rationale in casting a foot with CT restrictions that can be easily released first. This path then provides a higher success rate with the orthotic therapy because the body has one less complicating factor with which to manage.

    Hey, but don't just take my word for it. Lawrence B. wrote about this BFO (Blinding Flash of the Obvious!) when he first learnt FMT.

    And back in 1998, (I know, that was last century/millenium!) Gary Stamm, after doing an FMT course with me and a course with Tom Michaud wrote in 'NSW Footprints';

    'A patient with forefoot supinatus (RF), hypermobile 1st ray w severe push-off callosity medial to 1st MPJ. Took a cast for functional orthoses, then decided to mobilise the right tarso-metatarsus. This effectively produced an immediate forefoot rectus which the patient maintained in weight-bearing! So we had to re-cast didn't we?'

    He went on...

    'If a deformity can be reduced before casting, shouldn't we be doing it? If so, and if we aren't, hadn't we all better start learning how to?'

    I cannot see any benefit to any case with CT restrictions being cast for orthoses without mobilising first. An extra 5-10 mins of work is all it takes...

  3. Just exactly what internal temperature does a foot need to be to make a "good" negative impression? Do you think a few degrees of increase in internal temperature within the tissues of the foot is going to make a significant difference in the resultant foot casts?
  4. TedJed

    TedJed Active Member


    Are you being f'real or f'cetious?

    If f'real: 37.0 °C (98.6 °F) obviously.
    If f'cetious: 37.0 °C (98.6 °F) clearly.

    Actually, I don't think Michael is referring to a specific temperature when he says 'warm-up'.
    Rather, I think Michael is suggesting there may be a benefit in casting a foot that has maximum pliability and flexibility to minimise any false/altered soft tissue distortions of the foot contours e.g. a forefoot supinatus may be more exaggerated in a foot that has not been mobilised compared to one that has been mobilised. A bit like an athlete performs better once they 'warm up' rather than trying to perform 'cold'.

    Then again, Michael, you better clarify the meaning of your question rather than me 'assuming'.

    Yours Facetiously,
  5. Morning Kevin,

    By warm up I was not meaning core temp. I was as Ted said meaning making the foot more pliabiliable. If a person has had a ff supinatus for many years and as part of your casting tech. You decide that you will cast it out. Is is better to spend a few minutes getting the required Joints, ligaments and muscle more Pliablile or do you think that it better to grap the foot and evert the forefoot with no " warm up"?

    I´m coming at this from a Tissue stress point and considering Davis law.
  6. First you need to demonstrate that the "warm-up" will significantly alter the shape of the negative cast, then you need to demonstrate that this will significantly alter the shape of the completed orthoses, then you need to demonstrate that any difference in shape of the orthoses will significantly alter the outcomes.

    My guess- it won't make the slightest difference.
  7. I´m not thinking that the cast alone will be altered by this warm up, but that you will be able to manupulate the foot easier to get the resultant cast that you want.

    Say You wish to reduce the height of the MLA in a lateral deviated axis patient. This patient over time has reduced the length of certain ligaments and others have lengthened- Davis law.

    Now with your prescription you wish to change the Biomechancial function of the foot and obtain a changed STJ equilibrium, there I beleive will be an effect on the above ligaments, where maybe the short ones will be stretched thru increased tension loads and the long ones, will have less tension. Over time we will have a soft tissue change.

    My thoughts/ question are around will you be able to get a better cast impression if you "warm up" the foot before you reduce the height of the MLA in this example.
    Which down the road will get you a better device and better results from the patient.
  8. TedJed

    TedJed Active Member


    I propose that the 'warm-up' could result in no change in the shape of the negative cast. I then propose that a joint with improved RoM (read increased RoM in a hypomobile joint) could function more effectively on a functional orthosis.

    I acknowledge that this thread originally proposed a 'warm-up' to result in a change in the foot shape>change in orthoses>altered outcomes.

    I also acknowledge that your proposal would provide empirical evidence but it would be difficult to complete.

    I simply deduce that a joint which was hypomobile or stiff would function more efficiently (altered outcome) following mobilisation and casting for orthoses.

  9. If I want to lower the medial longitudinal arch of an orthosis I can: dorsiflex the first ray in the negative, add more medial addition, use a heel skive etc.

    Mike, you need to define what a "better cast impression" is.
  10. Two different topics, Ted. I'm not saying mobilization may not have therapeutic benefit, I'm saying that it makes no difference to the shape of the orthoses ultimately produced when used prior to casting.
  11. TedJed

    TedJed Active Member

    Yeah, I know...

    I have anecdotal experience to argue an alternative to this statement. Yes; anecdotal, not rigorous science.

  12. Good for you. I look forward to reading about it in a peer reviewed journal one day, until then I'll stand by my statement.
  13. Sorry rudely interupted by a patient.
    A better cast would be one which allows you to achieve your goals of your device with reduced modification to the positive cast. In this a case.

    If we discuss the MLA height again. I/we have decided to have a lateral skive and think that reduced MLA height of the device is a good idea. We have 3 different casts.

    1 standard Root negative

    2 A cast which has the pod manipulating the arch height to reduce it

    3 A cast after FMT which has allowed increase ROM of the joints that effect the position of the MLA and has pod manipulating the arch height. This would also require less force and therefore better control of what you are doing.

    My idea is that the 3 option should allow for less mods in the lab and may therefore have a closer fit to the patients foot , which make make the device more comfortable which as has been discussed very important in outcome.

    Hope that make sense.
  14. TedJed

    TedJed Active Member

    Yep, makes sense to me... that's what I'd do.
    Now for the blinded RCT to prove a logical deduction.
  15. How does mobilization of the foot ensure a closer fit, if you are then manipulating the foot during casting? A closer fit -when? Static stance? If I wanted a closer fit to a patients foot in static stance I'd use a weightbearing cast and not add any modifications- even less work for the lab. Do I need to mobilize the foot to achieve this? No. I don't buy that mobilizing the foot prior to casting is achieving anything that cannot be achieved without mobilizing it in terms of the casting process.
  16. Ok thanks Gentlemen for your input. I´ll go do somethinking on the subjest with your views in mind.

    Thanks again.
  17. I manipulate the foot during negative casting....pushing the foot joints where I want them to be for the 3D shape I want in the negative cast. I see no point in spending time manipulating the foot before casting.:drinks
  18. Graham

    Graham RIP

    Don't you just stand them in a foam box? It's so much quicker!:bang:
  19. Adrian Misseri

    Adrian Misseri Active Member

    G'Day all...

    In my opinion (and yes.. the kettle of fish is opened here), the plaster additions and modifications of the positive cast is MUCH more important. When casting, I'll manipulate out major deformities (i.e. plantarflexed/dorsiflexed 1st ray), and try to put the foot in the position I visualise that I want it in when it'll be standing on the device. Mind you, this is all done by eye and hand. Then, with my detailed notes that i put with my casts, I'll set about shaping my approxamate positive cast position to get exactly what I want. Sometimes I do capture a foot deformity (such as a plantarflexed/dorsiflexed 1st ray), but these are easily acounted for with good positrive plaster management.

    Just my thoughts...

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