Queensland Orthotic Lab, Author at Queensland Orthotic Lab Queensland Orthotic Lab, Author at Queensland Orthotic Lab

Is Your Orthotic Lab Giving You Custom Orthotics?

In a day and age where the customisation of orthotics is being called into question by health funds, the podiatry profession and the wider public, it’s increasingly important for the treating podiatrist to know exactly what is going on at their lab. Specifically, when you open up the packet with the patient’s orthotics inside, how do you know they have been custom made from the impression you took some 2-3 weeks earlier? If you get audited by a health fund, can you demonstrate that you have truly prescribed a custom orthotic? There are a few simple ways of knowing your patient’s devices are bespoke.

Is Your Lab Open to You Visiting?
Taking a day or even just a few hours out of your practice may be costly, but the value in spending that time at your lab is worth its weight in gold. It gives you the ability to see exactly what happens and the processes that your lab follows. You should be able to track your impression right the way through the facility to the end product. It’s also a great opportunity to troubleshoot any specific issues you may be having.

Does Your Lab Use Blanks/Library Devices?
The old saying that time is money is especially relevant in manufacturing. To save time, many CAD programs have the ability to use blanks or library devices. By taking measurements (lengths, widths, arch height etc), the software can superimpose the blank over the impression, thereby skipping many important steps to model a custom device. Note many labs are up front and sell their library devices separate from their custom devices at a lower price point which is the honest and transparent way. This enables podiatrists to service their patients if they don’t have the need for custom devices or are unable to afford them. However, there have been circumstances where podiatrists have unknowingly received library devices from their lab, thinking they were receiving custom devices.

Are All of Your Orthotics Symmetrical?
Following on from the point above, some labs make all of their devices to look symmetrical in an attempt to be more aesthetically pleasing. But does this reflect the morphology of the patient? If the patient has asymmetrical feet, why should the orthotics look symmetrical? How has that symmetry been achieved? Most CAD software has the ability to mirror. Thus, the lab can model one foot and simply mirror or flip to the other side, thereby saving time. But is this true customisation, or is it only 50% customised?

What Does the Lab Report Back to You?
To achieve true customisation of both feet, an assessment of the scans or casts must be performed prior to any modelling or plaster additions. That way, the lab can determine if one foot is longer, has differences in medial and lateral longitudinal arch heights, differences in widths at the heel, midfoot or forefoot, the forefoot to rearfoot relationship and any other osseous anomalies (e.g. prominent styloid process or navicular tuberosity) or soft tissue irregularities (e.g. plantar fibromas) which needs to be accommodated for. These should be reported back to the treating podiatrist so there’s complete transparency and understanding as to why the orthotic devices look the way they do. It also ensures the lab staff are manufacturing the device true to the patient’s anatomy. It’s not uncommon to see lab sheets being sent back to the podiatrist with notes such as left foot longer, left MLA lower, left midfoot wider as well as the forefoot to rearfoot relationship. Using this example, if we didn’t take the patient’s asymmetrical anatomy into consideration and just made symmetrical devices, we’d be making the right side unnecessarily lower, wider and longer or the left side unnecessarily higher, narrower and shorter. Both situations are likely to cause fit/tolerance issues.

How Accessible is Your Lab to Discuss your Orthotic Prescription?
Whilst some may see an orthotic lab as just being another supplier to a podiatry clinic, I believe the relationship between clinician and lab is an important relationship in helping to give the best patient outcomes. Clinicians must be able to call their lab (and vice versa) to discuss orthotic prescription parameters to optimise patient outcomes. That relationship between clinician and lab will develop over time where you get to know how each other works.

In summary there are several ways to critically evaluate your orthotics to determine the level of customisation that has gone into their production. It’s important to know exactly what you’re getting and how your lab operates to ensure you optimise patient outcomes.

Plantar Plate Tears

A common forefoot condition seen by podiatrists is an injury to the plantar plate, most commonly under the second metatarsophalangeal joint. The plantar plate is a fibrocartilaginous structure which attaches proximally to the plantar fascia and distally to the base of the proximal phalanx. It also has other ligamentous attachments including the deep transverse metatarsal ligament, the accessory collateral ligament, the proper collateral ligament as well as the extensor hood from the extensor tendons. It’s a highly complex piece of anatomy which is crucial in providing forefoot stability.

Clinically, patients typically present with central plantar forefoot pain, worse on propulsion. Oedema may be seen plantarly and/or dorsally. The floating toe or ‘V’ sign may be seen which tends to accompany partial or complete ruptures of the plantar plate. It can be mistaken for a Morton’s neuroma, but patients with a plantar plate injury typically have pain to palpate at the base of the proximal phalanx, whereas patients with a Morton’s neuroma tend to have pain in the intermetatarsal/interdigital space.

Plantar Plate Tear

The principles of treatment revolve around reducing the tensile strain of the plantar fascia and plantar plate. This may include digital plantarflexion strapping and a stiff shoe in early stages. We can also make up a forefoot stiffner for the shoe. This may be a 2mm piece of polypropylene in the shape of the forefoot of the shoe, which sits underneath the insole or orthotic.

When prescribing orthoses for patients with plantar plate tears, any orthotic modification which reduces plantar fascia strain will decrease strain to the affected plantar plate. These may include:

Casting/Scanning

  • Subtalar joint neutral
  • Midtarsal joint fully pronated (this will help to reduce plantar fascial strain)

Cast Modifications

  • Pour vertical
  • Intrinsic forefoot valgus posting
  • Plantar fascia accommodation (3-5mm)
  • Consider minimal arch fill

Shell Considerations

  • Semi-rigid to rigid materials
  • Anterior edge longer to the 2 nd metatarsal
  • Intrinsic forefoot valgus shape
  • Consider extrinsic forefoot valgus

Top Covers

  • Full length
  • Soft forefoot extension (e.g. 3.2mm poron)
  • Soft top cover (e.g. 2mm multiform)
  • An interesting discussion is around the use of metatarsal bars/domes – do these potentially
    increase strain through the plantar fascia and plantar plate?

Plantar plate injuries can be a common but at times challenging pathology to manage. By following the above mentioned principles and tailoring your treatment to the individual patient, most patients with this condition can be well managed conservatively.

Lab Tours

If you’re interested in learning more about how our orthotics and braces are made, or what accommodations and options are available when prescribing your devices, why not come in for a tour of our lab.

Richie Brace Adjustments

One of the more common questions we receive at the lab around Richie braces is around adjustments. Particularly if you don’t have a lot of experience with prescribing and fitting Richie braces, we find some podiatrists can be a little unsure I they can be adjusted.

Just like most custom foot orthotics, Richie braces are certainly easily adjusted. Both the footplate and the leg uprights are made from polypropylene, which means they can be spot heated and ground down if required. This means you can make most adjustments in your clinic, rather than inconveniencing the patient by taking their brace off them to send back to the lab. Let’s look at some of the common reasons you’d want to adjust a Richie brace at the time of fitting or at a follow up appointment.

Medial/Lateral Malleolous Irritation

In patients with adult acquired flatfoot, a high amount of force goes through the medial ankle as the tibia, somewhat disconnected to the foot by attenuated ligaments, internally rotates. This force can be so high in some patients that even light pressure from the medial upright of the Richie brace can be irritating or even unbearable in some cases. There are two simple adjustments that can be made to the brace if this is the case:

  1. Add an ‘extrinsic medial heel skive’. Cut a piece of EVA that is roughly half the width of the heel and extends from the posterior/plantar heel to the medial cuneiform. Grind a wedge/bevel so that it creates a medial wedge (thicker on the medial side). Glue this on top of the top cover to create and extrinsic medial heel skive. This will increase the rearfoot control and may reduce the medial malleolus irritation.
  2. Spot heat the medial ‘wing’ of the footplate. This is by far the most successful adjustment for this problem. Remove the upright pad and undo the Velcro straps. Spot heat the polypropylene on the medial wing of the footplate – just under the medial hinge. Once the plastic is hot enough (you’ll see it become quite shiny), place the brace on the desk/bench and push from the top of the upright down. This will cause the plastic to bow out at the medial malleolus. Note – you don’t need to try to push from inside the brace at the ankle region – just push from the top of the upright in an inferior direction. I find where people tend to go wrong here is when they’re not aggressive enough with pushing down. You can bow the plastic out quite a bit here to get the desired result. Of course the above adjustments can be reversed to the lateral side in the case of lateral malleolus irritation in the highly supinated foot type.

Push down on medial upright up high

Leg Upright Irritation

In patients with the inverted champagne bottle leg, the top of the leg uprights of the Richie brace
can cause some irritation. Again, being polypropylene, this means they can be easily spot heated.
Simply remove the pad and apply heat to the inside of the leg upright. Once the polypropylene is hot enough, you can then use your judgement to flare out the top of the upright enough to accommodate the patient’s leg anatomy.

Knowing how to perform these quick and easy adjustments can lead to increased patient compliance
and satisfaction, and increased confidence in prescribing the Richie brace in your practice.

Heat gun below the rivets on the foot plate upright

ScanMate Testimonial

We continue to hear from clients how ScanMate is revolutionising their digital scanning. One of our clients, Luke shared with us his experiences so far.

“I have been casting for custom orthotic therapy for the past 20 years. I have trialled two scanning systems in the past 10 years and at the end of each of these trials I reverted back to casting. In my opinion the technology had not yet been perfected. The savings in time and money were clear with a transition to scanning however the patient outcomes with traditional methods of scanning that I trialled were still lacking.

I am a firm believer that capturing the foot in a repeatable and reliable way with each and every scan translates heavily to achieving successful orthotic outcomes. Until trialling the ScanMate I had not found one scanning system that allowed me to place and hold the foot in a repeatable and reliable position (neutral) for each and every cast. The ScanMate allows the practitioner to easily hold the foot in a repeatable position with each and every cast regardless of patient age, weight, or injury.

ScanMate has allowed me to transition a practice of 11 podiatrists confidently to a complete digital scanning and prescribing system. I believe it has transformed the clinicians ability to greatly reduce inter-practitioner variability due to the ease and simplicity of the system.

If patient outcomes and reliable, repeatable scans are a priority in your business, ScanMate is a must.”

Luke, NSW

Getting the most out of your orthotics in the digital age

We continue to hear from Podiatrists the need for more education about the use of digital in our industry. In response to this demand, and in keeping with our commitment to supporting our clients, QOL is running a seminar “Getting the most out of your orthotics in the digital age”.

Register here to attend in person at Brisbane’s QUT Kelvin Grove on August 24.

Or if you’re unable to make it there, register here to receive the lecture digitally. This option will be available by the end of September for a reduced rate and is included free of charge for people attending the seminar.

Topics covered in the half day seminar include:
  • Scanning vs casting – can a scan be as good as a cast?
  • How to evaluate your scans
  • Orthotic prescription variables – how to prescribe the best device for your patient
  • Is 3D printing all it’s cracked up to be?
  • “Soft” & “hard” orthotics
  • Prescribing for specific conditions such as CMT, Charcot arthropathy, PTTD, plantar plate ruptures and more
  • Hands on scanning tips

Which Richie Brace Should I Prescribe for Dropfoot?

Treating complex neuromuscular conditions can be challenging. There are many factors to consider
which aren’t necessarily always examined in great detail if you were prescribing a foot orthotic.
However in my clinical practice, treating these patient are consistently the most rewarding patients.
In my experience, there are a number of patients who are wearing traditional AFOs who are not
happy with them. The dissatisfaction can stem from discomfort (rubbing etc), aesthetics and
material failure. However, if you’re armed with the right information, you can resolve these
problems and have a truly rewarding experience by allowing the patient to perform simple daily
activities that many people take for granted.

The first consideration when assessing a dropfoot patient for an AFO is knee stability. In terms of
knee stability, we look at the ability of the quadriceps, hamstrings and triceps surae muscles to
control the knee in the sagittal plane through stance. Most Richie brace models will not control
anterior migration of the tibia which accompanies knee flexion deformities. Genu recurvatum is
easier to treat with heel lifts or by placing the footplate of the brace into plantarflexion.

The second consideration is ankle range of motion. If the patient has passive ankle ROM beyond
90°, they may be suitable for a dynamic assist brace. However if the patient is unable to achieve at
least 90° of dorsiflexion (e.g. due to posterior spasm), the dynamic hinges may not be able to
overpower this force, leading to a loss of ground clearance in swing phase. The dynamic assist Richie
brace will achieve heel strike for dropfoot conditions if the patient has at least 90° of ankle
dorsiflexion. Remember an AFO can no correct a fixed equinus deformity.

Thirdly, calf strength is important. The dynamic assist Richie brace will achieve a normal gait pattern
as long as the posterior calf musculature is strong. You can check this by asking the patient to
perform a single leg calf raise. If the calf is weak, consider a restricted hinge Richie brace.

The fourth and final consideration is frontal plane deformity (varus or valgus alignment of the
rearfoot during gait). The dynamic assist Richie brace is the preferred brace for all dropfoot
conditions, but is less effective to correct severe varus or valgus deformities of the hindfoot. The
flexible hinges will give way, particularly in tall or obese patients. The restricted hinge Richie brace is
preferred when a severe varus or valgus deformity is present.

The dynamic assist Richie brace is the preferred brace for dropfoot conditions where there is good
stability of the knee, good ankle range of motion and lack of severe deformity of the hindfoot. Most
stroke patients and common peroneal trauma patients meet this criteria. Most patients find this
brace to be very comfortable and allow for normal daily activities such as walking up and down
stairs.

The restricted hinge Richie brace is preferred over the dyanimc assist Richie brace when the patient
has severe varus or valgus deformities, has ankle equinus, calf contracture or some instances of knee
instability. An example might be a Charcot-Marie-Tooth patient with an acquired cavo-adducto-
varus deformity of the foot.

By examining these simple criteria, you will be armed with the right tools to confidently prescribe a
Richie brace for your dropfoot patient and you should achieve an excellent clinical outcome.

Why ScanMate?

Since our inception in 1985, QOL has produced the highest quality hand-crafted devices. But it’s taken until 2019 before we introduced digital scanning options to our range. So you might ask, why didn’t we look into it earlier? The truth is – we did. In fact since the mid 1990’s when CADCAM options really started to become commercially viable, we’d been investigating options and kept up to date with the latest technologies. But we never found anything that met our high standards…so we invented ScanMate.

ScanMate was primarily developed with a key challenge in mind. The big roadblock for us was always – how do we take a scan of the foot that stays true to our values on how to take a cast of the foot? We’ve always advocated for a non-weight bearing cast of the foot, with the subtalar joint in neutral and the midtarsal joint fully pronated. This gives the best calcaneal pitch, medial and lateral longitudinal arch contours and enables the podiatrist to accurately capture the anatomical forefoot to rearfoot relationship. We know this gives us a more comfortable orthotic and better clinical outcomes.

So the challenge for us was to develop something that achieved this and still allowed the podiatrist to be hands free to operate the scanner. We also wanted something that could be used with the patient prone or supine. After significant research and development, we’re proud of what we’ve developed.

The difference in scans we receive between using and not using ScanMate are like chalk and cheese.

The development of ScanMate was a key piece in the puzzle of QOL offering a digital product. So whilst it may seem like we’re late with digital scanning, the reason is we were waiting until we felt we could produce something and put the QOL name behind it.

 

 

If you’re interested in an obligation free trial, contact us using the form below. 

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