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

Casting Tips to Improve Your Orthotic Outcomes

As one of the few remaining orthotic labs in the country to still provide a hand-crafted orthotic (using plaster modifications), we’re keen to continue this service. When manufacturing an orthotic this way, the emphasis of taking a good cast can’t be underestimated. A good cast is critical in producing a functional orthotic which is comfortable for the patient to wear. No amount of ‘lab discretion’ can replace capturing the patient’s anatomy in a repeatable manner. So what are the key elements in taking a good cast?

Patient Position
For supine casting, ensure the patient’s foot and distal 1/3 of the leg is hanging off the edge of the plinth. The lower leg should be horizontal or slightly declined.

If the leg is externally rotated, have the patient internally rotated at the hip or wedge up the lateral leg and thigh with pillows of towels. The long axis of the foot should be vertical.

Instruct the patient that you’ll need them to relax. For some patients this cue causes them to tense immediately! Ask them to let their whole leg go floppy. Look at the tibialis anterior tendon for signs of contraction.

Podiatrist Position
It’s critical that the podiatrist gets in the correct position. Ensure the patient’s foot is close to your chest. Keep the wrist in neutral so the bigger muscles of the shoulder are doing more of the work. This is one of the most challenging aspect of the casting techniques to master. Inexperienced practitioners may find this physically challenging. If this is the case, there’s a good chance you’re not in the correct position.

Load the MTJ
Insufficient loading of the midtarsal joint is one of the most common casting errors we see. In our experience there are more and more serious casting errors made in the positing of the midtarsal joint than in the positioning of the subtalar joint. In most feet, a few degrees of difference in the position of the STJ typically doesn't result in a dramatic change in the plantar shape of the foot. However, we see the MTJ as being more difficult to put in the proper casting position based on what we have seen in casts at the lab and in teaching students and practitioners the neutral position casting technique.

Insufficient forefoot abduction, dorsiflexion and eversion force can result in MTJ supination (i.e. creating a false forefoot varus), while excessive force can result in STJ pronation.

Work the Plaster
Use double layers of plaster and ensure good overlap between the rearfoot and forefoot splints. Spend some time initially working the plaster in to create a smooth, robust cast free of any air bubbles. Pay particular attention to areas of high curvature (e.g. medial longitudinal arch) so the plaster doesn’t gap from the foot.

Demonstrating air pocket in the medial longitudinal arch

Take Your Time
Don’t be in a rush to remove the cast. Removing it prematurely can undo all your hard work by causing the cast to buckle if it hasn’t set correctly. Setting times vary from batch to batch along with other external factors (e.g. temperature).

And Finally…
Don’t package your casts up straight away. They will continue to ‘sweat’ if put inside a box immediately, which again will undo all of your hard work. Ideally let them casts dry in ambient air for 24 hours prior to dispatch. Otherwise you can microwave for a few minutes the casts or use a heat gun on them to help them fully cure.

By following these steps, you’ll be sure to produce a good cast which accurately represents the patient’s anatomy. This will give your lab the best chance of manufacturing an orthotic to help give you great patient outcomes.

completed cast

Eliminating Paper Prescriptions

Do you want to eliminate paper forms and time spent scanning prescription forms in your practice? QOL have developed an online portal to allow you to upload prescriptions and digital scans in a secure
manner – MyQOL.

Even if you use physical casts (i.e. plaster, STS sock or foam box), you can still take full advantage of MyQOL. This allows you to go to a paperless ordering system and keep all of your prescriptions in one place. You can quickly search by first name, last name or job number to review old prescriptions. And if you wish to have that saved into your practice management system, it’s easy to save the completed prescription as a PDF and import into your patient file.

Unlike some competitors, we understand that feet are often asymmetrical. So when we receive the casts or scans, the first thing we do is to evaluate the feet and note if one foot it lower/longer/wider compared to the other foot. We communicate this through to our technicians but this also needs to be communicated back to you, the treating podiatrist. Just like our current paper prescription forms, we’ll make a note in MyQOL of things like the forefoot to rearfoot evaluation and any asymmetrical morphologies (e.g. one heel is wider than the other or one foot is longer the other). This allows you to see what we’ve seen in our measurements while also cross-referencing that to the actual orthotics.

The prescription form is set out almost identically to our paper prescription form and allows you to take advantage of our full range of traditional materials such as polypropylene, subortholen and carbon fibre and newer materials such as the 3D printed PA-11 and milled EVA. See MyQOL in action in this short video. If you wish to utilize our online portal, please register your interest in a trial here or contact the lab and we can set you up with an account.

Clinical Pearls for the Flat Foot Patient – Part 2

In part 1 of this 2 part blog, we explored the pathophysiology and clinical assessment of patients with a painful flatfoot. Understanding the stage at which your patient presents gives clear direction as to the best course of conservative treatment. This blog will focus on orthomechanical treatments. In all stages, physical therapy which includes balance exercises are critical and when appropriately coupled with orthomechanical care will lead to a much better chance of good outcomes. Of course surgery may be required in some cases, but with strict adherence to conservative treatments, surgery can be minimized.

 

Stage 1

In stage 1, we’re primarily dealing with a posterior tibial tendinopathy in a flat foot. In some cases, patients may require short-term immobilization to effectively settle their pain. Most patients in this stage benefit from a well-made custom foot orthotic. The pronatory forces are large in these patients (irrespective of the size of the patient themselves), so a large amount of force on the medial side of the subtalar joint axis is needed. As such, prescription parameters may include:

  • Semi-rigid to rigid shell material – 3.5mm to 5mm shell thickness.
  • Deeper heel cups – usually over 16mm.
  • Medial heel skive – 4mm and above.
  • Medial flare/flange – assists with transverse plane control through the talonavicular joint.
  • Extrinsic rearfoot post – increases rearfoot stiffness of the orthotic.

 

Stages 2-4

Usually by the time a patient is classified in stage 2, the key ligamentous structures (e.g. spring ligament) are involved which leads to discernable change in foot morphology – the symptomatic foot is flatter compared to the asymptomatic foot. Patients find it difficult to perform a single leg heel raise.

Where ligamentous involvement is clear, the preferred orthomechanical treatment is a custom ankle-foot-orthosis (AFO), rather than just a foot orthosis. The AFO helps to restore the coupling between the leg and foot which reduces with ligamentous attenuation or rupture.

The Richie brace is a custom AFO which podiatrists can prescribe from a cast of the lower leg and foot. For stages 2 and 3, the following prescription parameters can be followed:

  • Standard Richie brace – this allows for normal sagittal plane motion at the ankle (i.e. normal plantarflexion and dorsiflexion), but helps to restrict the pathological frontal and transverse plane forces acting through the rearfoot.
  • Medial heel skive – 4mm and above.
  • Lateral flare/flange – many of the patients have forefoot abduction and can slide laterally off the foot plate. A lateral flare/flange will control that forefoot abduction.
  • Full rearfoot post – the Richie brace range comes with a small heel stabilizer bar as the extrinsic post. Changing to a full rearfoot post increases the rearfoot stiffness of the AFO.
  • Medial malleolus accommodation – a lot of force is transmitted onto the medial upright in the area of the medial malleolus. This is required to resist internal tibial rotation. For some patients, this can be a source of irritation. By requesting a medial malleolus accommodation, extra plaster will be added to the area so the medial upright bows out in this area.

 

For stages 3-4 a standard Richie brace may not be sufficient to control the deformity, in which case the following prescription parameters may be better suited:

  • Medial arch suspender Richie brace – it is important to note that the medial arch suspender brace is built on a restricted hinge brace. This means the uprights are fixed at 90° to the foot plate which virtually restricts all sagittal plane movement at the ankle. A medial arch suspender strap can not be added to a standard Richie brace. To manufacture the medial arch suspender Richie brace, the plastic shell is cut out in a semi-circular shape under the medial longitudinal arch, a thin layer of cork is laminated in the area of the cut-out and a strap is attached underneath which wraps around the medial midfoot, across the anterior ankle up to a D ring on the lateral upright. The patient can then self-tension this strap.
  • Medial heel skive – 4mm and above.
  • Full rearfoot post – the Richie brace range comes with a small heel stabilizer bar as the extrinsic post. Changing to a full rearfoot post increases the rearfoot stiffness of the AFO.
  • Medial malleolus accommodation – a lot of force is transmitted onto the medial upright in the area of the medial malleolus. This is required to resist internal tibial rotation. For some patients, this can be a source of irritation. By requesting a medial malleolus accommodation, extra plaster will be added to the area so the medial upright bows out in this area.

Note the medial arch suspender Richie brace is contraindicated in very obese patients as the shell cut-out weakens the brace. It is also contraindicated for patients with severe forefoot abduction.

 

flatfoot collage

What If I’m Unsure?

We commonly talk with podiatrists who are unsure if they should prescribe the standard Richie brace or the medial arch suspender Richie brace. Generally speaking if the patient has a fairly rigid rearfoot with plantar subluxation of the medial cuneiform, the medial arch suspender Richie brace is appropriate.  If the rearfoot has normal or only slightly reduced range of motion and there is no plantar subluxation of the medial cuneiform, the standard Richie brace is more appropriate.

Finally, a standard Richie brace can be converted to a medial arch suspender Richie brace if needed. However a medial arch suspender Richie brace can not be converted back to a standard Richie brace.

 

 

Clinical Pearls for the Flat Foot – Part 1

When adults present to your clinic with ‘flat feet’, it can present an interesting enigma – why do some flat feet function normally and pain-free, yet other are painful and cause disability? We now know the answer to that question is the soft tissue changes that occur in some patients and not in other.

The dynamic supporting structures of the foot include:

  • Plantar aponeurosis
  • Posterior tibial tendon
  • Plantar intrinsic musculature – Dr Luke Kelly and colleagues have done some wonderful work in this area.

Whilst many are taught that the posterior tibial muscle and tendon are responsible for ‘holding up the arch’, we know through cadaveric studies that the plantar aponeurosis has a 3-fold greater power of arch support compared to the posterior tibial tendon.

The static supportive structures of the foot include:

  • Spring ligament complex
  • Superficial deltoid ligament
  • Interosseous talocalaneal ligament
  • Long and short plantar ligaments
  • Plantar aponeurosis – note both a static and dynamic supporting structure.

Two of the most prominent researchers in this area, Dr Jonathan Deland and Dr Mark Myerson, have repeatedly demonstrated that the sequential failure of these key ligaments is what causes a pathological flat foot, rather than an isolated failure of the posterior tibial tendon. This is why we prefer the term ‘adult acquired flatfoot’ rather than ‘posterior tibial tendon dysfunction’ to describe the much broader pathology.

That being said, it is important to note that patients will have a pre-existing flat foot and pathology will start in the posterior tibial tendon. The tendon will become inflamed and painful which is the first stage in any classification scheme. Accurately diagnosing patients with posterior tibial tendinopathy or tenosynovitis and managing them appropriately can have a drastic effect and stop them from progressing into a much more disabling pathology.

A thorough history taking is vital in these patients. They will usually give some good clues in their history. These may include:

  • A history of always having flat feet
  • More recently one foot has become painful
  • They are aware of swelling around the posterior aspect of the medial malleolus
  • In some patients they’ll be aware that one foot has become even flatter
  • Some patients may report some improvement in pain when wearing hiking boots

The key with the clinical examination is to conduct assessments which enables you to classify the patient. We recommend the following classification scheme based on the 2007 Myerson classification scheme and the 1989 Johnson & Strom classification:

Flat Foot Classification Scheme

The clinical examination should include the following:

  • Gait assessment – look for a limp which indicates pain and impairment. You may also detect the foot stays pronated in late midstance, when in fact it should be resupinating.
  • Single leg heel raise – arguably the most critical examination in these patients as this gives a good indication if there is ligamentous failure or not.
  • Jack’s test – look for resupination of the arch and external rotation of the leg.
  • Single leg Rhomberg – a simple balance test can be revealing for both the podiatrist and the patient.
  • Joint ROM (hip to toe) – is the deformity rigid or flexible?
  • Manual muscle testing – by isolating the posterior tibial muscle, both you and the patient can feel the weakness.
  • Supination lag – another muscle test where the patient is able to see the affected foot isn’t able to come towards the midline effectively.
  • Palpation for pain – is the pain isolated to the medial ankle or is the lateral aspect of the subtalar and ankle joints involved?

A thorough history and physical examination, coupled with a good understanding of the pathophysiology is vital in understanding the best treatment options for patients. If both you and the patient has an understanding of the extent of the pathology (i.e. isolated to the posterior tibial tendon or more widespread ligamentous involvement), effective treatment can be initiated.

 

 

How Should I Prescribe for Plantar Heel Pain?

Plantar heel pain is the most common presentation of musculoskeletal pain to most podiatrists in private practice.  There is still much debate on the cause of pain and the term ‘plantar heel pain’ probably encompasses several diagnoses.  For the sake of this blog post, we’ll focus primarily on what is commonly referred to as ‘plantar fasciitis’ or ‘plantar fasciopathy’.  This presents with the classic post-rest pain (or post-static dyskinesia). Note – if the patient doesn’t have post-rest pain, I’d be considering other differentials.  We know this condition affects more females than males, is more likely to occur in adults over 40 and is more likely in overweight or obese people.

If you’ve recommended custom foot orthotics be part of your treatment plan, are there prescription parameters you should consider?  Whilst I’m strongly against a cookie-cutter or recipe type approach to treating any pathology, there are certainly some prescription parameters to consider for plantar fasciitis.

Before we get to those prescription parameters though, I think it’s important to take a step back and think about what the likely contributing factors are.  In plantar fasciitis, I think there are a couple of key things which contribute to the development of this condition:

  1. Increased strain on the central band of the plantar fascia, and
  2. Increased ground reaction force on the heel.

We know that increased STJ pronation alone doesn’t lead to plantar fasciitis.  If that was the case, then only people with a pronated foot type would develop this problem.  We know that this problem can occur in any foot type – supinated, neutral or pronated (basic classifications, but you get the point!).

So if we need to look beyond the STJ as a mechanical explanation, what else could be contributing?  Potentially what can occur is: either a forefoot valgus or STJ pronation leads to 1st ray dorsiflexion and inversion – this causes the midtarsal joint to supinate, eccentric contraction of flexor hallucis brevis and abductor hallucis and a lowering of the MLA – these can all increase the strain on the plantar fascia.

In terms of treatment then, I think one of the best papers to give us a clue here, was Kogler’s 1999 cadaveric study.  Kogler and colleagues took 9 cadaveric specimens and inserted load transducers into the plantar fascia. Each specimen had an axial load through the tibia of up to 900 Newtons exerted through it.  6-degree wedges were applied in different combinations under medial and lateral rearfoot and forefoot and the load was measured through the plantar fascia. It was found that wedge under the lateral forefoot (forefoot valgus wedge) significantly decreased load through the plantar fascia, whilst a wedge under the medial forefoot (forefoot varus wedge) significantly increased strain through the plantar fascia.  Rearfoot wedging alone did not produce a significant change in plantar fascia strain.

When it comes to orthotic prescription then, what are some of the things you should consider?

How to take the impression:

  • STJ in neutral with the MTJ fully pronated (reduce forefoot supinatus by plantarflexing the first ray).  Capturing a forefoot valgus in the cast/scan provides a better outcome, rather than trying to ‘manufacture’ it in the design process!

Positive cast or CAD modifications:

  • Pour vertical
  • Plantar fascia accommodation (3-4mm), blended so as not to cause irritation on the medial or lateral margins of the accommodation
  • Potentially a minimal arch fill design if the foot mechanics warrants it
  • Accommodations for any fibromas or tears
  • Avoid medial heel skives (this can increase ground reaction force at the medial calcaneal tubercle)
  • Intrinsically post a forefoot valgus if captured in the cast/scan – this is critical!

Shell considerations:

  • Semi-rigid material, appropriate for foot mechanics, patient size and activities
  • Heel apertures and pads
  • Deep heel cups (>16mm)
  • Intrinsic forefoot valgus
  • Potentially extrinsic forefoot valgus wedging

Whilst we recommend you consider these prescription variables when prescribing orthotics for plantar fasciitis, it’s important to remember not to take a cookie cutter type approach to dealing with any pathology and to treat the individual in front of you.

Kogler GF, et al. The influence of medial and lateral placement of orthotic wedges on loading of the plantar aponeurosis. J Bone Joint Surg Am. 1999 Oct; 81(10):1403-13.

Prescription Advice for Treating the Cavus Foot

The cavus foot can be a challenge for podiatrists. Through the work of Professor Josh Burns and colleagues, we’re gaining a better understanding of the prevalence of foot pain and the impact this has on people with a cavus foot. We know that in people with a cavus foot common presenting complaints include metatarsal head pain, lateral ankle instability and peroneal tendinopathy. Therefore the goals of treating the cavus foot should include (but are not limited to):

  • Controlling/reducing forefoot forces
  • Increase the plantar surface contact area
  • Control frontal plane supinatory forces, especially at the subtalar joint
  • Pronate the midtarsal joint

The cavus foot should raise the clinical suspicion of underlying neuromuscular disease including Charcot-Marie-Tooth disease (hereditary sensory and motor neuropathy), muscular dystrophy, post-polio and cerebral palsy just to name a few. Of course patients may develop a cavus foot as a result of trauma, or it may be an idiopathic cavus foot.

As with all lower limb conditions that require orthotic therapy, the key is to start with a good cast or scan. Whether you’re using plaster or you’re scanning, it’s important to capture the complex curves of the cavus foot. This requires much more attention to detail in a patient with a cavus foot. Whilst capturing subtalar neutral position is important here, it’s absolutely critical that the midtarsal joint is fully pronated to capture what is typically a large forefoot valgus. By capturing the anatomical forefoot valgus of the patient, it makes the orthotic more effective at pronating the midtarsal joint and resisting subtalar joint supination.

Whilst most of the orthotics we do for cavus feet are poured vertical (or aligned vertically in our CAD program), doing an everted pour certainly has its place. It will increase the lateral arch contours, but you must also keep in mind it will decrease the medial arch height. Plantar fascial accommodations are typically used (usually 3-5mm) and lateral heel skives or cuboid notches can also be used to resist subtalar joint supination.

In terms of shell material, we typically advise to go for a more flexible shell material for the cavus foot. 2-3mm polyprolylene/subortholen/PA11 are commonly used materials. These are often reinforced laterally. For hand crafted devices we can reinforce the lateral side of the device with EVA. With PA11 (EnviroPoly) we can modify the design to have it printed thicker down the lateral side so it may be 2mm on the medial side and 3.5mm on the lateral side. We can also extend the extrinsic rearfoot post laterally to further reinforce the lateral side of the shell. Extrinsic forefoot valgus posting is another common addition to gain further lateral control. Heel lifts can be utilized in cases with equinus.

Whilst treating the cavus foot can be challenging, by understanding the goals of treatment, the casting/scanning requirements and the shell and post options, podiatrists should be able to gain good control to reduce pathological loads.

What Does A Podiatrist Do At An Orthotic Lab?

One of the common questions colleagues ask is “what exactly do you do at the lab?”. Whilst you don’t get the instant feedback that you get when treating patients, it’s rewarding getting to work with other podiatrists and knowing that your work is influencing hundreds of patients on a daily basis. We’ve got a fantastic team of orthotic technicians, most of whom have honed their skills over many years to really become master craftspeople, who do all of the hands on work. So what value does having a podiatrist at the lab give you and your patients?

1. Discussing Individual Cases With Podiatrists

We consult with most of our clients (both experienced and inexperienced) on a regular basis about their patients. Some are particularly tricky – think rare genetic disorders, complex neuromuscular diseases, amputations and complex post-surgical cases just to name a few. It’s not uncommon to receive videos and photos to help us understand the patient’s needs. Getting to help our clients and their patients is a really enjoyable part of the job.

2. Cast/Scan Evaluation

Whether our clients send us physical casts or digital scans we go through the same evaluation process. This is an important step in the process as it allows to be the link between the clinician and the technician. We assess both feet for lengths, widths (at the heel, midfoot and forefoot), arch heights, forefoot to rearfoot relationship and any other anomalies. So if one foot is lower and longer than the other foot, that information is communicated through to our technicians and the podiatrist. This way, when the podiatrist gets the orthotics back and they don’t ‘match’, they can see why that’s the case. We’ll also determine the appropriate metatarsal head bisections which helps to drive the shape of the finished orthotic.

It’s also an opportunity for us to troubleshoot any problems at the front end. We’d prefer to address any potential problems at this point, rather than making up a device and sending it back to the podiatrist only for them to think “this wasn’t what I was after”. For example, if we see set of casts from a patient with Charcot-Marie-Tooth disease with the typical cavo-varus deformity and the prescription has a 10° inverted pour, medial heel skive and 4° extrinsic rearfoot varus post, you can bet your bottom dollar that we’ll call the podiatrist to discuss the case.

3. Quality Control

Every orthotic and brace that leaves QOL is checked over by a podiatrist. We go over every detail of the prescription form with a fine tooth comb to ensure that firstly we’ve made the orthotic to the prescription (nothing has been missed etc) and secondly that it meets the high QOL standard. We want to ensure that when the podiatrist pulls the orthotics out of the bag, it’s exactly what they wanted when they were writing the script. We also ensure that when the patient sees the orthotic (and invariably pulls them out of their shoes when they get home and have a close inspection of them), they can see that they’re getting not only getting a great functioning orthotic, but also one that’s made to the highest quality and workmanship.

 

4. Keeping Up To Date With Orthotic Trends & Technology

As the experts in the field, it’s our job to keep up to date with the latest materials to ensure we continue to offer our clients the best options available. Suppliers are constantly giving us samples of new materials to trial. If we think a new material will be useful for our clients, we’ll go through rigorous internal testing before we make it available on our prescription form. It’s our job to cut through the marketing spin and ensure the material will perform and have appropriate longevity. We want to offer our clients the latest innovations in orthotics, but need to ensure we’re not going to run into problems 1 or 2 years later.

A great example of this is 3D printing. We felt that earlier 3D printing options (some of which are still be used in the industry) weren’t up to our standard. Whilst you can be seen to be innovative by being the first to 3D print, earlier materials were cracking/failing too readily for our liking. Therefore we decided to hold off until Nylon 11 (or PA-11) became commercially available and after rigorous testing, we felt this was appropriate option to offer to our clients.

Whilst working in a lab is very different to being a clinical podiatrist, we feel we’re drawing on our podiatry skill set, but just in a different way to a clinician. It’s really rewarding getting to help other podiatrists and knowing that together with our team of technicians, we’re using our heads, hearts and hands to help people get back on their feet.

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.