CHAPTER 72 • FOOTWEAR AND ORTHOTICS 435
on progressive deformity and loss of fore/rearfoot
flexibility (Benard et al, 2002; Sobel, Levitz, and
Caselli, 1999).
- Lower quarter stress fracture:Studies using vari-
ous orthotic devices have been shown to decrease
incidence of metatarsal, tibial, and femoral stress frac-
tures with shock absorbing materials as a primary
component of the device (Donatelli et al, 1988; Gross,
Davlin, and Evanski, 1991; Wayne Decker and
Stephen Albert, 2002; Ekenman et al, 2002; Finestone
et al, 1999).
- Medial tibial stress syndrome:A recent review of the
literature concluded there is some evidence for effec-
tive prevention of shin splints involving the use of
shock-absorbing insoles. Previous reports have
demonstrated significant clinical success treating shin
splints with various orthotic devices. The American
College of Foot and Ankle Orthopedics and
Medicine’s position statement is that custom foot
orthoses can be used to treat the symptoms of shin
splints and stabilize the etiology that causes the condi-
tion (James, Bates, and Osternig, 1978; Donatelli et al,
1988; Gross, Davlin, and Evanski, 1991; Benard et al,
2002; Thacker et al, 2002).
- Pes cavus:Orthotic management of the cavus foot has
been described to include an elevated heel, reduced
medial arch support, semi-rigid materials, first ray
cut-out, and a forefoot valgus wedge. Preliminary data
indicate 75% success with this type of device (Benard
et al, 2002; Manoli and Graham, 2001).
- Flexible flat foot: The symptomatic adult hyper-
pronated foot has been shown to be effectively treated
with various orthotic interventions regarding alleviat-
ing pain and deformity (Benard et al, 2002; Sobel,
Levitz, and Caselli, 1999; Noll, 2001; Bowman, 1997;
Kitaoka et al, 2002).
- Hallux valgus/Hallux rigidus:Custom orthoses have
been clinically shown to redistribute weight, prevent
excessive dorsiflexion forces and improve gait transi-
tion with pathology of the great toe (Benard et al,
2002; Churchill and Donley, 1998; Nawoczenski,
1999; Tang et al, 2002).
- Ankle sprain: Biomechanical foot orthoses have
been shown to be beneficial in improving postural
sway, balance, and decreased recurrent inversion
ankle injury with jogging following an inversion ankle
sprain (Orteza, Vogelbach, and Denegar, 1992;
Guskiewicz and Perrin, 1996; Hardoel et al, 2003).
•Low back pain has been shown to be effectively
treated with custom fabricated foot orthoses following
a comprehensive gait evaluation to address the patho-
mechanical process to decrease the degree of pain and
rate of reoccurrence (Dannanberg and Guiliano,
1999).
TYPES OF ORTHOTICS
- Accommodative:A device designed with a primary
goal of conforming to the individual’s foot allowing
plantar-grade floor contact that permits forces to be
distributed evenly to the foot (PFA, 1998). An accom-
modative device allows the foot to compensate and
yields to abnormal foot forces. It is primarily pre-
scribed to improve foot function and improve shock
absorption for patients who are poor candidates for
biomechanical devices secondary to congenital mal-
formations, restrictions of foot or lower quarter
motion, neuromuscular dysfunction, insensitive feet,
or physiologic old age. Most devices are full length
and total contact made of materials such as plastizote,
spenco, pelite, sorbathane, ethyl vinyl acetate(EVA),
and neoprene foam rubber.
- Biomechanical:A custom prescription device fabri-
cated specifically to address pathomechanical compo-
nents of a lower quarter condition by controlling and
resisting abnormal compensatory foot forces (Benard
et al, 2002). The prescription aspect of the device
involves clinical decision making for type of materials
to be utilized for rigidity, length of the device (full,
metatarsal, or sulcus), degree of correction/posting,
and depth of heel seat. Decision making should be
based on a comprehensive evaluation of biomechanics
and gait.
- Temporary:A device fabricated in the clinic primarily
for the purpose of assessing the need/benefit for per-
manent device; unloading tissues for healing; or control
hyperpronation. Common materials are aquaplast, or
orthopedic felt medial buttress and navicular-
sustentaculum tali support (Vicenzino et al, 2000).
SELECTION
- Specific aspects of subjective and objective examina-
tion guide clinical decision making for choosing the
proper components of a prescription custom fabri-
cated orthoses.
- Chief complaint/diagnosis including stage, inten-
sity, severity, and nature of the disorder
- Control versus bias of subtalar motion
- Mobility of the rearfoot, forefoot, midfoot, first
ray: hypermobile →normal →hypomobile
- Primary use of the orthoses. Street, sport, or dress
shoe to be worn in helps to determine material
selection and thickness. Specific sport and compe-
tition level also guide choice of components.
- Physiologic not chronological age; older patients
tolerate semirigid devices better and younger
patients tolerate more rigid management.
