Sports Medicine: Just the Facts

6. Need for shock absorption to dissipate ground
   reaction forces.


7. Weight of patient determines durometer (rigidity)
   of the orthotic.


8. Neurologic or anatomical abnormality helps to
   determine the need for accommodation with cut-
   outs, pressure distribution modifications, and
   material selection.

EVALUATION

• Specific components of a lower quarter evaluation are
  required to develop a treatment plan including custom
  foot orthotics based on The American College of Foot
  and Ankle Orthopedics and Medicine (ACFAOM)
  practice guidelines:
  
  
  1. Assessment of ROM, quality of motion and posi-
     tion of the ankle, rearfoot, and rear to forefoot rela-
     tionship
  
  
  2. Testing of specific lower quarter muscle strength
  
  
  3. Static stance position
  
  
  4. Leg length measurement
  
  
  5. Gait analysis
     6.Assessment of position, range, and quality of
     motion of other lower quarter structures including
     spine, hip/pelvis, knee complex, 5th ray, 1st ray, 1st
     metatarsophalangeal (MTP), 2–5th MTP joints,
     and interphalangeal (IP) joints (Benard et al, 2002).
  
  
  
  


• Numerous techniques have been used to capture the
  foot for fabrication of a custom orthoses (Benard
  et al, 2002). Plaster casting, preferable when captur-
  ing rearfoot to forefoot relationship, is of prime
  importance for fabrication of a functional device
  (Laughlin et al, 2002). Weight bearing measures of a
  loaded foot to determine forefoot posting have been
  proven reliable and further investigation into clinical
  application needs to be evaluated for orthotic pre-
  scription and fabrication (Cummings and Higbie,
  1997). Neutral suspension casting with the foot posi-
  tioned by holding the sulcus of the 4th and 5th toes
  obtained in prone or supine is the preferred method
  for a functional prescription foot orthoses (Benard
  et al, 2002).
  1.Plaster cast:The goal is to capture the relationship
  of the forefoot to rear foot and reproduce the ideal
  position of the foot in midstance just prior to heel
  off.
  2.Compressive foam box: Partial weightbearing
  technique most appropriate for accommodative
  devices—with the benefits of simplicity of use/clean
  up; but typically provides an inconsistent represen-
  tation of forefoot relationship (Benard et al, 2002;
  Langer, 1996).

3.Computer imaging/scanning:Another technique

to capture the contour and shape of the foot for

orthotic fabrication where the device is milled

from image or a positive model of the foot is cre-

ated. The benefits of an imaging system are exact-

ness of forefoot to rearfoot relationship for posting,

created in partial or nonweightbearing and sim-

plicity of use—with the drawback of expense

(Benard et al, 2002).

REQUIREMENTS

• Requirements for successful orthotic intervention are
  based on patient/condition specific goals developed
  following a comprehensive subjective and objective
  evaluation as stated previously. The device must have
  certain components to increase treatment success and
  compliance.
  
  
  1. Conform precisely to all contours of foot espe-
     cially heel, calcaneal, and forefoot inclinations
  
  
  2. Rigid enough to maintain shape, contour, and
     angular relationships
  
  
  3. Control abnormal motion, allow normal motion,
     and provide proper sequencing/timing of motion
  
  
  4. Improve muscle function
  
  
  5. Able to withstand stress and wear
  
  
  6. Comfortable to assure compliance
  
  
  7. Adjustable
     8.Minimum length ends at least proximal to
     metatarsal heads
  
  
  8. Narrow enough to fit in shoes and allow 1st and 5th
     rays function
  
  
  
  

DEVICE ASSESSMENT/USE

• Once the custom orthosis has been fabricated, evalua-
  tion of the patient wearing the device must be com-
  pleted based on goals of management from the initial
  biomechanical and gait evaluation.
  
  
  1. Subjective response
  
  
  2. Treadmill/track for 10–20 min
  
  
  3. Areas of irritation
  
  
  4. Gait changes/corrections
  
  
  5. Static correction of calcaneal position
  
  
  6. Develop a progressive wear schedule: Typically 1 h
     first day; gradually increase use 60 min/day; ath-
     letic use following tolerance of 4–6 h general use
  
  
  7. Proper shoes to work with device are extremely
     important to maximize the benefits of the device.
     Some of those basic shoewear components are a
     stable heel counter, removable insert, and deeper
     heel cup.
  
  
  
  

436 SECTION 5 • PRINCIPLES OF REHABILITATION