PHASIC POSTING Putting The Function Into Foot Orthoses. Bob Longworth MSc DPodM Lee Short MSc

Transcription

1 PHASIC POSTING Putting The Function Into Foot Orthoses Bob Longworth MSc DPodM Lee Short MSc

2 A Phasic Posting approach to insoles AGENDA 1. What is a functional foot orthotic? 2. Problems with the theories behind insole production 3. Casted Vs Chairside: Pros & Cons 4. How to effectively target insole treatment 5. How to use technology to inform prescriptions

3 George and Mildred

4 How long have orthoses been around? Leg braces found in Ancient Egyptian tombs (Bunch 1985). In 1845 Durlacher constructed a leather inlay used to treat mechanical foot problems (Payne 1998). There s a patent from1924 where contoured metal, rubber and wood were used on cast impressions of feet.

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6 What is a functional foot orthotic? Dr Merton Root started experimenting with orthoses made to casts of a neutral foot in By 1965, working with with Drs Weed and Sgarlato, the Root Functional orthosis was born. R. Anthony (1991)

7 2. Problems with the Theories behind insole production Based around The concept of STJ neutral

8 STJ Measurement reliability Palpation of STJ neutral - poor inter-tester reliability Elveru et al 1988 McPoil and Hunt 1995 Pierrynowski et al 1996 Menz 1997 And as most measurements are taken with the STJ in neutral..

9 Are Podiatric measurements valid??? Elveru et al 1988 McPoil and Hunt 1995 Pierrynowski et al 1996 Van Gheluwe et al 2002 Podiatric biomechanical measurements show poor inter-tester reliability

10 Is STJ Neutral the ultimate foot position? McPoil 1988 Garbolos 1994 Sobel et al 1999 Cornwall 2001 STJ Neutral is not a normal foot position

11 Does the foot function around STJ neutral? No! McPoil and Cornwall 1994 Moseley et al 1996 Pierrynowski et al 1996 Hunt et al 2001 Is STJ Neutral theory valid???

12 Casted Vs Chairside: Pros & Cons CASTED ROOT ORTHOSES CHAIRSIDE XLINE/VECTORTHOTICS Set protocol (Lab calls the shots) No set protocol (it s up to you) Need to cast the foot No plaster of paris/scanner/oasis boxes required Delay in treatment whilst insoles made Instant treatment Better fit as made from a cast Only fit average feet Permanent device Temporary Unable to make it permanent Look more professional Bulky Relatively expensive Relatively cheap

13 Advantages of casted insoles Made from a cast of the foot so must be a better fit! How accurate is the cast? How much of that contour remains after the plaster additions?

14 R. Anthony 1991 p.77

15 Better fit.? And how many labs actually use this technique.? And how many labs just give you the closest fit off the shelf..?

16 Advantages.cont. Permanent device. What if symptoms change? What if long term use not required? And casting can be messy.

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18 Prefab device ADVANTAGES Quick Cheap Easily adjusted Just as effective Trial run DISADVANTAGES Temporary Look cheap Bulky Hard to reproduce a permanent device from one

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21 Disadvantages Temporary devices - Don t last as long Vectorthotics - up to 3 years Xline - up to 12 months Still, you have to cast for a permanent insole don t you?

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27 How to effectively target insole treatment Phasic Posting approach: What s hurting? Orthopaedic testing + Palpation Anatomy Other investigations When does it hurt? At what point in the gait cycle does pain occur (when is that tissue stressed) Will an insole help? Is this condition amenable to insole therapy How can we influence the phase of gait where the problem arises

28 Practical session: Patient 1 History: Noticed a pain on medial side of Left ankle that started 2/12 ago after a long walk. Patient feels that the Left foot has got flatter since then. Probable diagnosis?

29 Practical session: Patient 1 Confirm diagnosis with Orthopaedic testing. When does that structure become stressed in the gait cycle? Can we influence that stage of the gait cycle with an insole?

30 Practical session: Patient 2 History: Always had weak ankles I could trip over fresh air!. Last 6/12 developed a Right sided, persistent anterio-lateral ankle pain after treading awkwardly on a curb. Probable diagnosis?

31 Practical session: Patient 2 Confirm diagnosis with Orthopaedic testing. When does that structure become stressed in the gait cycle? Can we influence that stage of the gait cycle with an insole?

32 Practical session: Patient 3 History: 40 year old man C/O Shin Splints since he took up jogging. Had never ran before but is training for a ½ marathon. Probable diagnosis?

33 Practical session: Patient 3 Confirm diagnosis with Orthopaedic testing. When does that structure become stressed in the gait cycle? Can we influence that stage of the gait cycle with an insole?

34 Practical session: Patient 4 History: 35 year old female with heel pain. Hurts with initial weight bearing and throughout the day. She s a nurse and does long hours on her feet. Probable diagnosis?

35 Practical session: Patient 4 Confirm diagnosis with Orthopaedic testing. When does that structure become stressed in the gait cycle? Can we influence that stage of the gait cycle with an insole?

36 & now for Mildred

37 How Can In Shoe or Pressure Plate data help with insole prescription?

38 What Sort of insole would you prescribe for this patient How does this patient walk?

39 Does this help

40 This is the data taken with a laterally post insole So is this patient walking better now?

41 Is this really good enough

42 A Lateral posted orthosis and stiffened lateral shoe

43 Now will this do

44 How to use technology to inform prescriptions F-Scan approach: 3 rocker scenario Using in shoe data, we can show where problems occur in gait Using insoles/shoe adaptations, a more normal gait can be shown

45 Primary pivots during the stance phase of gait that are essential for sagittal plane facilitation (0-60% = 60%) Heel pivot (0-10% =10%) Initial contact and loading response. Flexion at the knee is caused by the heel rocker action and body s COM behind the foot. Shock absorbtion at the knee. Stability established while maintaining forward progression.

46 Ankle joint pivot Midstance 10-30% = 20% Forward rotation of the tibia at the talo-crural joint. Foot remains flat on the floor. Talo-crural joint changing from plantarflexion to dorsiflexion. Calf muscles contracting eccenticly.

47 Forefoot and hip pivot. Forefoot pivot (Terminal stance) 30-60% = 30% Third pivot produces a second peak in vertical force exceeding body weight (f=ma). High activity of the calf muscles to maintain the third rocker. TFL restrains the increasing posterior hip vector. Hip joint should reach 150 extension

48 What sort of gait does this patient have?

49 Does this help

50 Does this help 57 Y/O Male Severe Haemophilia B (F9) R x 2 ankle arthrodesis (last 1999) Right Fixed 15 degree equinus on long leg (15 deg range into plantarflexion) Left 15 deg DF to 30 deg PF Long standing Multi level Disc probs. MRI 2007 L4/5 disc bulge L>R with L4/5 root impingement. L5/S1 Paracentral Disc bulge impinging on L5 Nerve root.

51 Does This Help

52 With orthoses

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55 FFO s and Modified Boots

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58 So Can you make an insole purely from pressure data The Footscan system does 2D data to make a 3D structure How accurate is it going to be? Ethically ok to make without seeing the patient? What do the labs do?

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60 We Now know that after all this analysis that you will get the best fit of 3 arch heights; high medium or low Windle et al (1999)

61 QUESTIONS?

62 References Anthony R.J. (1991) The manufacture & use of the functional foot orthosis Basel, Karger Bunch W.H., (1985), Introduction to Orthotics, in Bunch et al, Atlas of Orthotics, 2nd edition, The C.V. Mosby Company, St.Louis. Elveru RA, Rothstein JM and Lamb RL (1988): Goniometric reliability in a clinical setting-subtalar and ankle joint measurements. Physical Therapy: 68(5): Hamill J, Bates BT, Knutzen KM, Kirkpatrick GM. (1989) Relationship between selected static and dynamic lower extremity measures. Clinical Biomechanics 4(4): Hunt, A.E., Smith, R.M., Torode, M., Keenan, A-M. (2001) Inter-segment foot motion and ground reaction forces over the stance phase of walking. Clinical Biomechanics. 16(7): Keenan, A-M. (1997) A clinician s guide to the practical implications of the recent controversy of foot function The Australasian Journal of Podiatric Medicine 31(3):87-93 LaPointe, S.J. Peebles, C. Nakra, A. Hillstrom, H. (2001) The reliability of clinical & caliper-based calcaneal bisection measurements Journal of the American Podiatric Medical Association 91(3): Landorf K.B. and Keenan A-M. (1998) Efficacy of foot orthoses: what does the literature tell us? Australasian Journal of Podiatric Medicine 32 (3): McPoil, T.G. Hunt, G.C. (1995) Evaluation & management of foot & ankle disorders: Present problems & future directions Journal of Orthopaedic & Sports Physical Therapy 21(6): McPoil TG and Cornwall MW (1994): Relationship between neutral subtalar joint position and pattern of rearfoot motion during walking. Foot and Ankle 15: McPoil, T.G. Cornwall, M. W. (1996) The relationship between static lower extremity measurements & rearfoot motion during walking Journal of Orthopaedic & Sports Physical Therapy 24(5): Menz H.B. (1995) : Clinical hind foot measurement: a critical review of he literature. The Foot Menz, H.B. (1997) Clinical measurement of the lower extremity - where to from here? The Australasian Journal of Podiatric Medicine 31(3): Moseley, L. Smith, R. Hunt, A. and Gant, R. (1996) Three dimensional kinematics of the rearfoot during the stance phase of walking in normal young adult males Clinical Biomechanics 11(1): 39-45

63 References.cont. Payne C.B., (1998), The past, present and future of Podiatric Biomechanics Journal of the American Podiatric Medical Association 88(2): Pierrynowski, M.R., Smith, S.B. and Mlynarczyk J.H. (1996) Proficiency of foot care specialists to place the rearfoot at subta- lar neutral. Journal of the American Podiatric Medical Association 86: 217 Redmond, A. Lumb, P.S.B. Landorf, K. (2000) Effect of cast & noncast foot orthoses on plantar pressure & force during normal gait Journal of the American Podiatric Medical Association 90(9): Root, M.L., Orien, W.P., Weed, J.H. (1977) Normal and Abnormal Function of the Foot: Volume II. Los Angeles, Clinical Biomechanics Corporation. Sobel, E., Levitz, S.J., Caselli, M.A., Tran, M., Lepore, F., Lilja, E., Sinaie, M. and Wain, E. (1999) Reevaluation of the relaxed calcaneal stance position. Journal of the American Podiatric Medical Association 89, Van Gheluwe, B. Kirby, K.A. Roosen, P. and Phillips, R.D. (2002) Reliability and accuracy of biomechanical measurements of the lower extremities Journal of the American Podiatric Medical Association 92(6): Windle, C.M., Gregory, S.M. and Dixon, 5.1. (1999). The shock attenuation characteristics of four different insoles when worn with a military boot during running and marching. Gait and Posture 9,