Ordering Orthotics

 

A Physicians Guide to Ordering Custom Orthotics and Bio Engineered Devices

 

Introduction

Both the Foot & Custom Bio-Engineered Devices (including Orthotics) are Three Dimensional Objects, (3D).   Both work in all three body planes.   The Custom Devices must be able to properly align rearfoot to midfoot anatomy and properly resist closed kinetic chain and cyclic load stresses resulting from joint pathomechanics (lack of wedge locking) and maintain resilience and structural integrity of the materials used.  

 

Biomechanical Consultant - Dr Craig Lowe

I am here to help. . .  No ego here. . .I am retired, but I do have over 40 years of experience and also have a good amount of research and development experience.   Double Board Certified (Surgery and Orthopedics) with Fellowships in Orthopedics, Microsurgery, Laser Surgery and Sports Medicine - "This and 50 cents will by be a cup of coffee today", States Dr Lowe (lol).

• Skype Video Conferencing - Skype Name = Dr Craig Lowe
• Log Me In Sessions
• Phone Conferencing

Lab Discretion versus Physician Ordering

Lab Discretion is where the physician discusses diagnosis and or pain conditions and the seasoned Laboratory Technicians evaluate Static and Dynamic data and determine the best custom configuration for Rx. 

• Custom Product is fully guaranteed

Physician Ordering is where the provider select from the Accommodation and Modification section of Digital Imager Live Software and determines what ehty want in the Rx.

• Custom Product is not guaranteed.   If the patient does not get the desired results, changes or modifications (repairs) may be needed and there will be a fee for technician time and materials.

Four Orthotic Types:
 

1.  Bio-Engineered Devices 

• The best and most accurate (3DO Imaging Only)

 

 

 

 

2. Orthotics from Laser, Plaster Casts

• Vunerable to "Art Form" and 27 error points
• May not correct or partially correct deformities

 

3. Accommodative from Foam Boxes, Plaster Casts and 3DO

• Used to offload pressure but does not control joint locking
• Not corrective

4.  Pre-Fabricated

• Works on assumption we all have the same feet.
• Usage by foot size
• Not corrective

 

Errors in Orthotic Manufacturing Link: http://errorsinorthoticmanufacturing.blogspot.com

 

Selecting the proper Stressed Induced Thermoplastic

Digital Orthotics uses a unique thermopressprocess under pressure and heat to maximize the plastic's ability to maintain shape without material breakdown.  

 

The plastic comes 1/8" durometer (flex) and 3/16" durometer (rigid).  

• Linear Movement (forward motion (walking - running - hiking):  Patients weight between 50 to 165 pounds should used 1/8" durometer.   Patients between 165 and 180 can have crepe fill to increase moderate additional rigidity.   Patients between 180 and 250 pounds use 3/16" durometer.  Patients over 300 pounds can have crepe in the arch to add additional rigidity. 
• Rotational Movement:   Sport activities such as basketball, racketball, tennis, football etc requires the foot to supinate and pronate and so the devices are made of 1/8" flex thermoplastic.  

Sample Video Lab Production Process - 2005



Heel Cup Depths

• Female 4 to 6 mm
• Male 8 mm (style dress slip on shoes) to 12 mm Oxford
• Extra Dept Heel Cup (UCBL) is usually around 22 mm and is used for extreme rearfoot and midfoot pronatory disease as well as unstable gait conditions.

 

Top Covers

• Shock Absorption - High Memory Urethanes.    Thickness comes in 1/16" - 1/8" - 3/16"
• Self Accommodation - Diabetic and hypersensative Feet
• Dual Laminate Poron and Plastizote - Excellent for Diabetics, hypersensative and atrophic feet
• Wicking Materials (used to absorb moisture)
• Low - Moderate - High Durometer Crepe
• Length of Top Covers (Full - Sulcus (3/4) - Orthotic Only (1/2)) 

 

 

Accommodations & Modifications

• Metatarsal Pads - High impact forefoot loading in lesser metatarsal areas.  Example - Intermetatarsal Neuromas.   Also used for Tylomas and callouses from depressed metatarsals.  Metatarsalgia and metatarsal bursitis.  
• Heel Cut Outs for high impact calcaneal hot spots, (heel spurs & bursitis)
• Medial & Lateral Flange (UCBL) used to control high pronatory conditions
•  

 

Footwear Integration
The biggest challenge with Orthotics and Bio Engineered Devices is the integration of these devices into footwear.   We alleviate most of the problems through our footwear ordering process on Digital Imager Live.  

 

If there is ever a question on integtrating custom devices, I recommend you either take a digital Photo of the shoes and attach the photo to the production order, or better yet, send the shoes to us for integration.   This is a great service we provide for difficult types of footwear, (High Fashion - Specialized applications such as AFO bracing).   Simply send us the shoes and we will integrate and adjust the custom Bio Engineered Devices to fit perfectly.



Transverse Plane Deformities - Result of abnormal foot pronation.   Rearfoot (Subtalar) Posting is manditory to control excessive transverse limb rotation. 

 

Foot & Ankle Pronation

• Rearfoot valgus (everted rearfoot) and eversion due to excessive midtarsal joint varus and hypermobile 1st Ray conditions.
• Ankle Joint Pronation due to excessive tibial torsion (> 18 degrees)
• Bunions 1st MPJ and 5th MPJ 
• Metatarsal Shear in Diabetics with hypermobile feet and neuropathy

Sub Talar Joint Variations

Midtarsal Joint Axis

 

 

Leg - Tibial Torsion (excessive or lack of. . )

• Excessive tibial torsion leads to abducted feet and significant pronatory disease of limb.  
• Shin splints of the anterior compartment of the lower leg.



Knee

• Chondramalascia of the patella (abnormal patella tracking)
• Medial and lateral co-lateral ligament strain
• ACL and PCL syndromes



Hip

• Sciatica, Trochanteric Bursitis, Synovitis, DA

Spinal

• Pain from excessive internal limb rotation

 

Frontal Plane Deformities 

Foot

• Rearfoot valgus (everted rearfoot) and eversion due to excessive midtarsal joint varus and hypermobile 1st Ray conditions.
• Ankle Joint Pronation due to excessive tibial varum (> 18 degrees)
• Hypermobile 1st Ray - Hallux Abductus - Metatarsal Primus Varus  

Leg

• Tibial Varum (bow leg)
• Medial and lateral co-lateral ligament strain
• Short leg syndromes

Knee

• Coxa Vara Genu Valgum - Severe knock knee position due to femoral and tibial mal-alignment
• DA (Degenerative Osteo) of knee
• Scolosis leg Shortages

Pelvic & Spine

 

Lateral Plane Deformities - Reducing Equinus influences are vital to good treatment.   Effective devices re-center mass into midfoot from forefoot.

 

 



 

Foot

• Hammertoes
• Neuromas
• Plantar Fasicaiitis
• Equinus - A major deforming force

Knee

• Genu Recuvatum (hyper-extension)
• Equinus
• DA Knee

Hip

• DA Hip

Spinal

• Equinus
• Lordosis and low back pain syndrome - usually associated with equinus 

 

Standard and Fashion Footwear Integration

 

Fashion Footwear

 

Linear Sports

 

 



 

Rotational Sports

 

 

 

 

 

Conclusion & Remarks:  The advantage of 3DO (3D Weight Bearing Kinematic Imaging) is its ability to see the unseeable 3D bio-physics of disease and drive neutral position via software.

1. Mass Displacement Analysis
2. Motion Analysis
3. Pressure Analysis (linear and shear)
4. Body balance
5. Symmetry
6. Gait Analysis
7. 3D Plantar Geometry (measurements)