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Post by ianl on May 7, 2008 9:06:42 GMT
Hi
Guess that options are as different as the practitioners.
One would be:
Basic Foot cast just below stj neutral. Cast poured vertical 1/8 inch polyprop shell with intrinsic 2deg forefoot post (apex of medial arch to come around the navicular area), posted laterally. (don't know if there is a heel varus component so options for lateral heel skive exist to create pronation moment) 3-4mm forefoot extension in poron with cut out for 1st and 5th mets.
Further options that can be added include: a possible option of 1st ray cut out to cunieform. a small single met cookie heel raise
Rehab peripheral joint mobs, soft tissue manipulations Assess hip structure rom with view to referal for physio muscle balance approaches more proximal (periph mob of hip by Pod a possible option as well).
Of course we might be surprised with simply keeping to the basic and then seeing if there is need for anything else! ;D
Cheers Ian
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Post by robertisaacs on May 7, 2008 9:18:44 GMT
Actually i have not seen the patient either! And i think its a GOOD photo . Dodgy photo indeed. Cheek. Like that alot. Perhaps something shank dependant in EVA or lunarsoft would be better than a shell? What poron are we talking about here? Slow release as in diabet memory foam type stuff or poron 94 lambda superkittenysoft. I would think in either of those situations there would be some structural change observable in NWB. However its a good point. Regards Robert
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Post by robertisaacs on May 7, 2008 9:27:15 GMT
Hey Ian Sorry, confused. So we cast just BELOW STN, then increase the arch height with a 2 degree intrinsic forefoot post then post the whole thing laterally from the heel. Is the intrinsic so that the arch is the same height after the heel has been laterally posted? Careful buddy, You might get chucked out of the KISS club ;D . What is your objective here. Are we trying to pronate or supinate and how do you see this affecting the forefoot lesions? Regards Robert
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Post by ianl on May 9, 2008 8:15:16 GMT
Hi Robert Sorry for the delay. Quote: Foot cast just below stj neutral. Cast poured vertical 1/8 inch polyprop shell with intrinsic 2deg forefoot post (apex of medial arch to come around the navicular area), posted laterally. (don't know if there is a heel varus component so options for lateral heel skive exist to create pronation moment) Your questionSo we cast just BELOW STN, then increase the arch height with a 2 degree intrinsic forefoot post then post the whole thing laterally from the heel. Did not actually say that though in fairness it was a poorly written post so could be misconstrued as such. I thought I had suggested that the option of the heel skive is determined by the presence of a varus heel in which case I would not use a forefoot valgus post. Is the intrinsic so that the arch is the same height after the heel has been laterally posted? What is your objective here. Are we trying to pronate or supinate and how do you see this affecting the forefoot lesions? First question based on misunderstanding of my poor post so not relevant. I have used the intrinsic posting method almost all the time and in this instance, because of the lateral 5th lesion have assumed (due to minimally available detail) that there is a possible prolonged lateral loading component or restricted STJ movement possibly generating an adductury heelwhip etc. If these are the case then I have found in the past that a low valgus intrinsic posting creates a pronation moment and aids reducing the prolonged loading of the lateral column and lesion area. An additional 5th met cut out has sometime been necessary but certainly not always. Only twice in 12 years of orthotics have I had an issue with arch height problems working this way. In effect I suppose I am generating a pronation moment at some points and a resistence (apex of arch around Navicular/MTJ area) to pronation at others, that the foot seems able to adapt to quite nicely. Hope this is a bit clearer Or not Ian Careful buddy, You might get chucked out of the KISS club .
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Post by robertisaacs on May 9, 2008 11:33:49 GMT
Oh i see! that makes sense now.
Ta
Robert
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Post by robertisaacs on May 12, 2008 13:30:31 GMT
I suppose i should offer my ideas here (having picked at other peoples! ;D). My thinking was as follows. Can't offload all the met heads with problems because that would only leave 3&4 to load onto. Can't rely on a sagital plane rocker because she is mainly static. Don't want to raise the heel (increase forefoot load) Don't want to do much if any frontal plane stuff because supination moments will increase the 5th met head load and pronation moments will increse 1st met head load. The lesions 1st and 5th mpj are HDs (peak pressure). Only the second met head is pure callus (whole met head pressure). Can't offload 1 and 2 met heads altogether, no reason why i can't offload the lesions and still use the rest of the met heads! Therefore prescription was : - 3mm poron over cork base. 6.35mm poron pad across PMA with small, corn size cavities (slots actually) for the two corns but still loading on the rest of those MPJs A cutout with an ultrasoft poron 94 button for the second met head. Mild valgus pad. The rational being Decrease spot load on 1 & 5 and deflect off of 2nd. Offer some cushioning to all (3mm poron base). Like this With a mild arch pad so that the pmp coforms to the foot. Here is a thought. If that foot came to you for "palliative care" and you were going to do a Semi compressed felt pad, how would you do that? Regards Robert Regards
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Post by dtt on Jun 8, 2008 17:08:45 GMT
Hi Robert I used a 5mm latex pmp in tubigrip posterior to the met heads but extending to the 2nd met with the 1/5 offload. It worked for a short time but as the pad wore the lesions returned BUT The patient has returned for routine care yesterday ( yes it was one of mine) after wearing your footprints orthotics and the soft tissue has improved by 70% Thank you Robert ;D ) The patient was not willing to go with the scanning Rx orthotic system I use in my practice I will await her next return after debriding all and see how much the tissue has recovered ( I will post the result) ;D cheers all and thanks all for your input D
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Jude
New Member
Posts: 47
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Post by Jude on Jun 19, 2008 21:13:07 GMT
I'm with TimVS "Check range of motion and joint stiffness. Is there a functional equinus here? Loads of FF pressure. Hard to tell but looks like 1st ray is plantar flexed and rigid/semi-rigid, including the hallux? So an accommodative flexible device to the sulcus or even full length with maybe a 1st ray cut out. . Lots of padding on the top cover. Minimal posting. Encourage supportive walking boots with nice thick soles for her sponsored walks. Check with the tekscan if device is offloading the pressure areas sufficiently and adjust accordingly. Mobilisations perhaps. Active/passive stretches post. compartment if required"
Just like to add check postural ailignment, some trainers and postural training.
When do we get the answers?
Do we get before and after pics?
Robert lets have much more of this may be one a month...............
Jude
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Jude
New Member
Posts: 47
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Post by Jude on Jun 19, 2008 21:21:24 GMT
Oh dear too late did not turn to page 2 to look at the anwers got to excited and peeked to early.
Jude
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Post by dtt on Jun 20, 2008 11:21:51 GMT
Hi Jude I seem to remember doing that myself in the past ;D D
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Post by robertisaacs on Jun 20, 2008 18:19:54 GMT
;D There are no "answers", just opinions. I rather liked tims answers too. He's had his small prize (freebies ) Regards RObert
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ians
New Member
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Post by ians on Jun 28, 2008 6:38:58 GMT
Hi Robert Love quizzes.I would love to understand some of them treatments. I do better trying to understand plantar pressures at present.Is this the wrong way? Did fast track in SMAE (Root Bio i think) I have been trying to move from semi compressed felts stuck to the patients foot.(as a treatment not like chewing gum) On my first visit pare offending corn/callus and pad. Encourage patient to review shoes and if poss get shoes with a built in sock liner in the future. If they already have a built in sock liner, and don't mind it being doctored, start padding or cutting that in the corresponding positions. In future visits assess whats going on and use double sided carpet tape and 3 or 6mm poron on their sock liner or make up 3mm poron insole and deflective padding. I have had minimal success. Do i move too slow in resolving?Should the corns and callus disappear with the pad/post/cast? You guys seem to hit it on the head in one blow. Thanks for your patience and Dtt's patient. Ian
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Post by robertisaacs on Jun 28, 2008 19:50:50 GMT
Hey ian. No Shame in starting biomechanics with planter pressure manipulations. That is a valid field and can be well developed. There is quite a bit of information on "simple" insoles (what you describe with carpet tape and poron) here. www.davidmhol.proboards29.com/index.cgi?board=bioed&action=display&thread=200Which may be of use to you. Reply number 8 is particularly relavant to forefoot redistribution. Whether the lesion improves, resolves, or just sits and grins at you depends on several factors. The length of time the lesion has been there, its precise aetiology, the degree of structural deformity / functional abnormality which must be accomodated and the amount of room you have to play with are key. A good understanding of the actual function of the foot is also important in redistributive insoles as is an understanding of the materials and techniques available. To paraphrase Dave S, its about finesse. A 6mm poron or felt U pad does something in most cases. However if you can be more targeted it can give better results per mm thickness available. So far as "proper" (read traditional) biomechanics goes IMO root is the place to start. However it has been built upon and refined by several models since including tissue stress, rotational equilibrium and sagital progression. Root can also lead you a merry dance in terms of measuring of unmeasurable and insignificant angles. Its easy to get tangled up in this in favour of simpler but more significant observations. Its not simple enough to be "simple" biomechanics and not involved enough to be "complex" biomechanics. As i say, you have to start there. But it is the foundation only. The house is built upon it. The whole of the biomech education page on this site is there just for you to ask questions and gain clarification so please, don't be afraid to ask anyone anything. Regards Robert
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ians
New Member
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Post by ians on Jun 30, 2008 7:55:26 GMT
Hi Robert thanks for that. I have posted a few questions on the board there. Tissue stress, Rotational equilibrium and Sagital progression?(that does sound like a very technical way of describing a toilet function) ;D. Joking aside. Would you recommend anywhere to further this knowledge kind sir? Ian
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Post by robertisaacs on Jun 30, 2008 10:10:07 GMT
I can give you some references / sent you some journal articles if you pm me your email address. However some of them are a bit challenging if you are not coming from an academic background (or even if you are!). The concepts are, in essence, not hard. However they tend to be wrapped in enough jargon and technicalities to put scare people off.
I am running a foundation biomechanics course on the 3rd august, one day, informal and from the basics up. If you have £40 and a sunday spare this might be helpful.
Regards Robert
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