Question 1

Medial wedges

Accepted Answer

A medial wedge may be added to your orthotics to align your foot and improve function, particularly if you have collapsed arches and excessive inward movement (pronation) when you walk. Orthotics with medial wedges are thicker along the inside and thinner along the outside, which helps to redistribute forces away from the problematic area of your foot, increasing control and having a stabilising effect. This addition is particularly helpful for bunions (hallux valgus). By redistributing forces away from the inside of your foot, a medial wedge can reduce bunion pain and slow bunion deformity. Medial wedge orthotics have been shown to prevent deformity in rheumatoid arthritis, and are also helpful for flat feet, tarsal tunnel syndrome, plantar fasciitis, big toe joint arthritis, sinus tarsi syndrome and posterior tibial tendon dysfunction, which have all been linked to excessive pronation. Our patients with midfoot osteoarthritis have also benefited from a medial wedge addition to their orthotics, as it helps to redistribute forces in the midfoot area. At Open Podiatry, the degree and positioning of your medial wedge will depend on your foot structure and function, as well as your pathology. References Norouzi, Ehsan, et al. Comparison of the Effect of Custom-made Medial Arch Support Insole with and without Medial Sole Wedge on the Degree of Pain and Hallux Valgus by Digital Imaging Immediately and after Six Weeks of Use." Archives of Pharmacy Practice 1 (2020): 79. Woodburn J, Barker S, Helliwell PS. A randomized controlled trial of foot orthoses in rheumatoid arthritis. J Rheumatol. 2002 Jul;29(7):1377-83. Kogler GF, Veer FB, Solomonidis SE, Paul JP. The influence of medial and lateral placement of orthotic wedges on loading of the plantar aponeurosis. J Bone Joint Surg Am. 1999 Oct;81(10):1403-13. Chapman GJ, Halstead J, Redmond AC. Comparability of off the shelf foot orthoses in the redistribution of forces in midfoot osteoarthritis patients. Gait Posture. 2016 Sep;49:235-240. Scherer PR, Sanders J, Eldredge DE, Duffy SJ, Lee RY. Effect of functional foot orthoses on first metatarsophalangeal joint dorsiflexion in stance and gait. J Am Podiatr Med Assoc. 2006 Nov-Dec;96(6):474-81.

Question 2

Lateral wedges

Accepted Answer

A lateral wedge may be added to your orthotics to align your foot and improve function, particularly if you have abnormally high arches and your feet are prone to rolling outwards (supination). Orthotics with lateral wedges are thinner along the inside and thicker along the outside, which helps to redistribute forces away from the problematic area of your foot and stabilise it. Lateral wedges are particularly helpful for chronic ankle instability and peroneal tendonitis. At Open Podiatry, the degree and positioning of your lateral wedge depends on your foot structure and function, as well as your pathology. References Sobel E, Levitz SJ, Caselli MA. Orthoses in the treatment of rearfoot problems. J Am Podiatr Med Assoc. 1999 May;89(5):220-33. Williams DS 3rd, McClay Davis I, Baitch SP. Effect of inverted orthoses on lower-extremity mechanics in runners. Med Sci Sports Exerc. 2003 Dec;35(12):2060-8. Mündermann A, Nigg BM, Humble RN, Stefanyshyn DJ. Foot orthotics affect lower extremity kinematics and kinetics during running. Clin Biomech (Bristol, Avon). 2003 Mar;18(3):254-62.

Question 3

Kirby skive

Accepted Answer

A Kirby skive (or medial heel skive) may be added to the inner side of the heel cup of your orthotics, to slightly change the position of your rearfoot when you are walking. This changes the forces going through your heel, which stabilises your foot and helps you have more controlled motion. This addition can improve pain and function in conditions such as collapsed arches, flat feet or posterior tibial tendon dysfunction. At Open Podiatry, we prescribe different depths of Kirby skive for your heel, depending on how much control you require. References Bonanno, D.R., Zhang, C.Y., Farrugia, R.C. et al. The effect of different depths of medial heel skive on plantar pressures. J Foot Ankle Res 5, 20 (2012). Banwell, H.A., Mackintosh, S., Thewlis, D. et al. Consensus-based recommendations of Australian podiatrists for the prescription of foot orthoses for symptomatic flexible pes planus in adults. J Foot Ankle Res 7, 49 (2014).  Kirby K: The medial heel skive technique. Improving pronation control in foot orthoses. J Am Podiatr Med Assoc. 1992, 82 (4): 177-188.

Question 4

Lateral heel skive

Accepted Answer

A lateral heel skive may be added to the outer side of the heel cup of your orthotics, to change the forces going through your outer heel. A lateral heel skive is helpful if you have abnormally high arches, which can lead to ankle instability, peroneal tendonitis and knee pain. This addition helps to control your foot when you are walking and reduces pain. At Open Podiatry, we prescribe different depths of lateral heel skive for your heel, depending on how much control you require. References Wukich DK, Tuason DA. Diagnosis and treatment of chronic ankle pain. Instr Course Lect. 2011;60:335-50.  Richie DH Jr. Effects of foot orthoses on patients with chronic ankle instability. J Am Podiatr Med Assoc. 2007 Jan-Feb;97(1):19-30.

Question 5

Metatarsal dome

Accepted Answer

A metatarsal or ‘met’ dome is a small addition that may be used to enhance your orthotics by lifting and spreading your metatarsal bones. This is particularly helpful if you experience pain or discomfort in the ball of your foot when you stand or walk, such as a neuroma. A met dome supports your forefoot and helps to alleviate pressure in this area, which relieves pain. Our patients comment that met domes can feel strange at first, but the relief they feel is often instant and they soon get used to their orthotics. We use met domes that are made from a soft, spongy material (such as Poron®), to maximise your comfort.  References Landorf, K.B., Ackland, C.A., Bonanno, D.R. et al. Effects of metatarsal domes on plantar pressures in older people with a history of forefoot pain. J Foot Ankle Res 13, 18 (2020). Lee, P.Y., Landorf, K.B., Bonanno, D.R. et al. Comparison of the pressure-relieving properties of various types of forefoot pads in older people with forefoot pain. J Foot Ankle Res 7, 18 (2014).

Question 6

Metatarsal bar

Accepted Answer

A metatarsal or ‘met’ bar may be added to your orthotics to transfer the forces from your metatarsal heads to other parts of these bones. This is a helpful addition if you have bony, prominent metatarsal heads in the ball of your foot, which is a common occurrence in conditions such as rheumatoid arthritis and diabetes. A met bar can help to relieve pain forefoot and can also help to reduce areas of abnormally high pressure, preventing hard skin, corns, and even foot ulcers. References Ahmed, S., Barwick, A., Butterworth, P. et al. Footwear and insole design features that reduce neuropathic plantar forefoot ulcer risk in people with diabetes: a systematic literature review. J Foot Ankle Res 13, 30 (2020). Kang JH, Chen MD, Chen SC, Hsi WL. Correlations between subjective treatment responses and plantar pressure parameters of metatarsal pad treatment in metatarsalgia patients: a prospective study. BMC Musculoskelet Disord. 2006 Dec 5;7:95.  Tenten-Diepenmaat, M., Dekker, J., Heymans, M.W. et al. Systematic review on the comparative effectiveness of foot orthoses in patients with rheumatoid arthritis. J Foot Ankle Res 12, 32 (2019).  Postema K, Burm PE, Zande ME, Limbeek Jv. Primary metatarsalgia: the influence of a custom moulded insole and a rockerbar on plantar pressure. Prosthet Orthot Int. 1998 Apr;22(1):35-44.

Question 7

Morton’s extension

Accepted Answer

We may add some material to your orthotics underneath where your big toe joint sits, to reduce movement or completely stop this joint from moving. This is known as a Morton’s extension. This addition is helpful if you experience painful arthritis in your big toe joint, known as hallux rigidus. By limiting movement in the big toe joint with the use of a stiff material added to orthotics, our patients usually find that their pain disappears. References Munteanu SE, Landorf KB, McClelland JA, Roddy E, Cicuttini FM, Shiell A, Auhl M, Allan JJ, Buldt AK, Menz HB. Shoe-stiffening inserts for first metatarsophalangeal joint osteoarthritis: a randomised trial. Osteoarthritis Cartilage. 2021 Apr;29(4):480-490.

Question 8

Reverse Morton’s extension

Accepted Answer

A reverse Morton’s extension may be added to your orthotics to increase the range of motion in your big toe joint. This addition involves extending material from the tip of your orthotics to your 2nd-5th metatarsal heads. A reverse Morton’s extension is useful if you have lost some motion in your big toe joint, but it can be improved. At Open Podiatry, we often use reverse Morton’s extensions when big toe joint arthritis is in its early stages, and to improve the function of the big toe joint when you have a bunion. Some of our patients also find that a reverse Morton’s extension is helpful forplantar fasciitis, because it reduces tension on the plantar fascia. References Menz HB, Auhl M, Tan JM, Levinger P, Roddy E, Munteanu SE. Effectiveness of Foot Orthoses Versus Rocker-Sole Footwear for First Metatarsophalangeal Joint Osteoarthritis: Randomized Trial. 2018 Sep;70(9):1420]. Arthritis Care Res (Hoboken). 2016;68(5):581-589. Lynch, DM, Goforth WP, Martin JE, et al. Conservatie treatment of plantar fasciitis. A prospective study. J Am Podiatr Med Assoc 88(8):375-380, 1998.

Question 9

Heel raise

Accepted Answer

A heel raise (or heel lift) may be added to your orthotics to elevate your heel, especially if you have problems with your Achilles tendon, which is the structure that connects your calf muscle to the base of your heel. The Achilles tendon transfers power from your calf muscle to your heel and foot, allowing you to walk, run, stand on your tiptoes and jump. The high forces going through this tendon can sometimes result in pain and inflammation, known as Achilles tendinitis. At Open Podiatry, we add heel raises to our orthotics to raise the height of your heel, taking the pressure off your Achilles tendon. Our heel raises also have shock absorbing properties to prevent further injuries. A heel raise may also be used to address a leg length discrepancy, which may be leading to other pathologies. We may also add temporary heel raises to orthotics for Sever’s disease, a painful condition seen in children (usually aged between 8-15 years), to reduce tension on the Achilles tendon during growth spurts. References Wulf M, Wearing SC, Hooper SL, Bartold S, Reed L, Brauner T. The Effect of an In-shoe Orthotic Heel Lift on Loading of the Achilles Tendon During Shod Walking. J Orthop Sports Phys Ther. 2016 Feb;46(2):79-86. doi: 10.2519/jospt.2016.6030.  Severin AC, Gean RP, Barnes SG, Queen R, Butler RJ, Martin R, Barnes CL, Mannen EM. Effects of a corrective heel lift with an orthopaedic walking boot on joint mechanics and symmetry during gait. Wiegerinck JI, Zwiers R, Sierevelt IN, van Weert HC, van Dijk N, Struijs PA. Treatment of calcaneal apophysitis: wait and see versus orthotic device versus physical therapy: a pragmatic therapeutic randomized clinical trial. J Pediatr Orthop. 2016;36:152-157.

Question 10

Arch reinforcement

Accepted Answer

We may add arch reinforcement to your orthotics, especially if you have collapsed arches or flat feet. This addition is comprised of firm material that provides extra support in the arch area. Our patients find that arch reinforcement is comfortable, relieves their foot pain and helps them feel more stable when standing and walking. Arch reinforcement is particularly helpful if you are on your feet all day or you work on uneven surfaces. References Blake, R., Huppin, L., Kirby, K. Keys to orthotic modifications for patients who work on their feet. Podiatry Today, October 2014.

Question 11

Cuboid pad

Accepted Answer

A cuboid pad can be added to your orthotics to raise your cuboid bone, which is a short, pyramid shaped bone in the outer part of your foot. A cuboid pad can relieve cuboid syndrome, which causes displacement or subluxation of the bone. This causes pain and weakness in this area of the foot when walking. This orthotic addition supports the cuboid bone and corrects its position to relieve pain. References Durall CJ. Examination and treatment of cuboid syndrome: a literature review. Sports Health. 2011;3(6):514-519. Mooney M, Maffey-Ward L. Cuboid plantar and dorsal subluxations: assessment and treatment. Journal of Orthopaedic & Sports Physical Therapy. 1994 Oct;20(4):220-6.

Question 12

Heel spur horseshoe pad

Accepted Answer

A heel spur is a bony projection that occurs at the bottom of the heel, making standing and walking painful. An oval or horseshoe shaped addition creates a depression in the heel area of your orthotics, and is added if you have a painful heel spur. This addition helps to offload this area and increases shock absorption when you walk, reducing pain. References Ferguson H, Raskowsky M, Blake RL, Denton JA. TL-61 versus Rohadur orthoses in heel spur syndrome. J Am Podiatr Med Assoc. 1991 Aug;81(8):439-42.

Question 13

Plantar fascia groove

Accepted Answer

The plantar fascia is a tough band of tissue that runs across the bottom of your foot, connecting your heel bone to your toes. It supports the arch of your foot. When it becomes strained through overuse, it causes plantar fasciitis – pain in the heel. Orthotics have been shown to improve plantar fasciitis. However, sometimes our patients with this pathology have found that previous orthotics have irritated their plantar fascia, causing discomfort, and have stopped wearing them. At Open Podiatry, we often add a plantar fascia groove to orthotics prescribed for this condition. This accommodates the plantar fascia, and is particularly helpful if this structure is tight and prominent. The groove is pressed into the orthotic, allowing the plantar fascia to drop into it. The precise location of the groove is based on your specific foot structure, which helps to reduce pressure on your plantar fascia and allow it to recover. References Roos E, Engström M, Söderberg B. Foot orthoses for the treatment of plantar fasciitis. Foot Ankle Int. 2006 Aug;27(8):606-11.

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