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1. ACHILLES TENDONITIS
Characterized by inflammation due to micro tears within the tendon or inflammation of the subcutaneous and subtendinous bursae. The condition is aggravated by tension on the tendon due to equinus conditions, stretching the tendon too early in the therapeutic process, impact activity that involves forcing the foot into dorsiflexion

Footwear Considerations:
• Firm, snug-fitting and deep heel counter in the shoe
• Internal (up to 6mm if no heel lifts are added on to the orthotics) and/or external heel lifts made from an incompressible material
• Shoe laces to be tightly secured (diabetics excluded)

Orthotic Considerations
Strongly Recommended:
• Order as high an arch profile as the patient will be able to tolerate (depending on the patient’s non- weightbearing arch height, degree of arch collapse on weightbearing, their age, activity level, level of tolerance to changes, etc.)
• Incorporate 3mm to 6mm heel lifts (these should be reduced in height once the condition has improved, again making sure the heel counter of the shoe can accommodate the increased height without the patient’s heel slipping during walking)
Optional
:
• Incorporate 2mm medial heel skives if the patient shoes excessive calcaneal eversion on weightbearing
• Incorporate plantar fascial grooves (mark these on the patient’s foot with lipstick before making the impression), if the patient presents with a prominent medial slip of the plantar fascia on dorsiflexion of the hallux
• Incorporate a deep heel cup if excessive calcaneal eversion is noted on weightbearing. (The heel cup depth should be greater than 14mm and up to 20mm, making sure that the heel counter of the shoe will allow the increased width that accompanies a deeper heel cup)
• Incorporate Morton’s Extensions if the patient presents with short 1st metatarsals
• Incorporate soft medial flanges in cases of extreme navicular drop on weigthtbearing, (making sure that the shoe can accommodate the increased width associated with this addition)

2. CALLUSES
Calluses develop because of excessive pressure in a specific area of the foot. The intermittent “on-off” pressure during gait causes the capillaries feeding the germinal cells of the epidermis to become “leaky.” This increases epidermal cell growth in the region. The same pressure also prohibits desquamation of the outermost layer of the epidermis leading to impacting, and over time, to the formation of keratin.

Footwear Considerations:
Firm, snug-fitting and deep heel counter in the shoe
• Shoe laces to be tightly secured (diabetics excluded)

Orthotic Considerations
Strongly Recommended
:
• Pronation Related: Order as high an arch profile as the patient will be able to tolerate (depending on the patient’s non- weightbearing arch height, degree of arch collapse on weightbearing, their age, activity level, level of tolerance to changes, etc.)
• Supinated Foot Type Related: Ask for 25%-50% cast dressing on the plaster positive cast
• Incorporate metatarsal pads to create a transverse arch support in the forefoot which serves to offload the metatarsal heads
• Specify additional cushioning in the forefoot to reduce shock related pain
• Ask the lab to create depressions in the top cover to offload severe callus. This should be done after accurate marking in the negative impression
Optional
:
• Incorporate 3mm heel lifts if a muscular equinus condition exists
• Incorporate 2mm medial heel skives if the patient shoes excessive calcaneal eversion on weightbearing
• Incorporate plantar fascial grooves (mark these on the patient’s foot with lipstick before making the impression), if the patient presents with a prominent medial slip of the plantar fascia on dorsiflexion of the hallux
• Incorporate a deep heel cup if excessive calcaneal eversion is noted on weightbearing. (The heel cup depth should be greater than 14mm and up to 20mm, making sure that the heel counter of the shoe will allow the increased width that accompanies a deeper heel cup)
• Incorporate Morton’s Extensions if the patient presents with short 1st metatarsals
• Incorporate soft medial flanges in cases of extreme navicular drop on weigthtbearing, (making sure that the shoe can accommodate the increased width associated with this addition)

3. MORTON'S NEUROMA
This pathology is caused by the impingement of two adjacent metatarsal heads on the proper digital branches of the medial plantar nerve. The constant shearing of the adjacent metatarsal heads “thickens” the nerve sheath in the region. The most common site for a Morton’s Neuroma is in between the 3rd and 4th metatarsal heads where the medial and lateral columns of the foot meet. The etiology is one of abnormal subtalar joint pronation, which leads to this shearing action during each step of the gait cycle. Narrow shoes that squeeze the metatarsal heads together further exacerbate this condition
Conservative management (short of surgery) strives to limit the abnormal pronation (and thus the shearing action between the metatarsal heads and to separate the metatarsal heads so as to relieve the lateral pressure on the nerve

Footwear Considerations:
• Firm, snug-fitting and deep heel counter in the shoe
• Shoe laces to be tightly secured (diabetics excluded)
• Wide toe box in the shoe to eliminate the squeezing action on the metatarsal heads

Orthotic Considerations
Strongly Recommended
:
• Order as high an arch profile as the patient will be able to tolerate (depending on the patient’s non- weightbearing arch height, degree of arch collapse on weightbearing, their age, activity level, level of tolerance to changes, etc.)
• Either incorporate metatarsal pads to create a transverse arch support in the forefoot which serves to separate the metatarsal heads or use a neuroma pad (a thin wedge shaped pad) placed on the upper surface of the orthotic (between the adjacent metatarsal heads at the site of the neuroma) to create the separation
Optional:
• Incorporate 3mm heel lifts if a muscular equinus condition exists
• Incorporate 2mm medial heel skives if the patient shoes excessive calcaneal eversion on weightbearing
• Incorporate plantar fascial grooves (mark these on the patient’s foot with lipstick before making the impression), if the patient presents with a prominent medial slip of the plantar fascia on dorsiflexion of the hallux
• Incorporate a deep heel cup if excessive calcaneal eversion is noted on weightbearing. (The heel cup depth should be greater than 14mm and up to 20mm, making sure that the heel counter of the shoe will allow the increased width that accompanies a deeper heel cup)
• Incorporate Morton’s Extensions if the patient presents with short 1st metatarsals
• Incorporate soft medial flanges in cases of extreme navicular drop on weigthtbearing, (making sure that the shoe can accommodate the increased width associated with this addition)

4. CLAW TOES
A claw toe is a toe that is contracted at the PIP and DIP joints (middle and end joints in the toe), and can lead to severe pressure and pain. The etiology usually involves long standing digital retraction due to extensor over pull. Claw toes may occur in any digit, except the hallux. There is often discomfort at the top part of the toe that is rubbing against the shoe and at the end of the toe that is pressed against the bottom of the shoe.
Claw toes are classified based on the mobility of the toe joints. There are two types - flexible and rigid. In a flexible claw toe, the joint has the ability to move. This type of claw toe can be straightened manually.
A rigid claw toe does not have that same ability to move. Movement is very limited and can be extremely painful. This sometimes causes foot movement to become restricted leading to extra stress at the “ball” of the foot, and possibly causing pain and the development of corns and calluses.

Footwear Considerations:
• Deep, wide toe-box to accommodate the deformity
• Firm, snug-fitting and deep heel counter in the shoe
• Shoe laces to be tightly secured (diabetics excluded)

Orthotic Considerations
Strongly Recommended:
• Order as high an arch profile as the patient will be able to tolerate (depending on the patient’s non- weightbearing arch height, degree of arch collapse on weightbearing, their age, activity level, level of tolerance to changes, etc.)
• Incorporate metatarsal pads to create a transverse arch support in the forefoot, which serves to offload the metatarsal heads. When upward pressure is applied to the proximal metatarsal heads, the digits extend horizontally (flexible claw toes only) forward preventing the clawing to become long standing and therefore rigid
• Specify additional cushioning in the forefoot to reduce shock related pain
• The use of external toe props to offload the apices of the digits
Optional:
• Incorporate 3mm heel lifts if a muscular equinus condition exists
• Incorporate 2mm medial heel skives if the patient shoes excessive calcaneal eversion on weightbearing
• Incorporate plantar fascial grooves (mark these on the patient’s foot with lipstick before making the impression), if the patient presents with a prominent medial slip of the plantar fascia on dorsiflexion of the hallux
• Incorporate a deep heel cup if excessive calcaneal eversion is noted on weightbearing. (The heel cup depth should be greater than 14mm and up to 20mm, making sure that the heel counter of the shoe will allow the increased width that accompanies a deeper heel cup)
• Incorporate Morton’s Extensions if the patient presents with short 1st metatarsals
• Incorporate soft medial flanges in cases of extreme navicular drop on weigthtbearing, (making sure that the shoe can accommodate the increased width associated with this addition)

5. METATARSALGIA
Characterized by pain in the “ball” of the foot, metatarsalgia is due to a variety of etiologies: plantarflexed metatarsals due to extensor over-pull accompanied by digital retraction; hypermobility of the 1st ray due to peroneus longus weakness allowing the bulk of the plantar load to fall on the 2nd to 4th metatarsal heads; distal shifting/atrophy of the fibro-fatty pad under the metatarsal heads due to digital retraction or advanced age respectively. Shoes without cushioning in the forefoot exacerbate this condition

Footwear Considerations:
• Firm, snug-fitting and deep heel counter in the shoe
• Shoe laces to be tightly secured (diabetics excluded)

Orthotic Considerations
Strongly Recommended:
• Order as high an arch profile as the patient will be able to tolerate (depending on the patient’s non- weightbearing arch height, degree of arch collapse on weightbearing, their age, activity level, level of tolerance to changes, etc.)
• Incorporate metatarsal pads to create a transverse arch support in the forefoot which serves to offload the metatarsal heads
• Specify additional cushioning in the forefoot to reduce shock related pain
Optional:
• Incorporate 3mm heel lifts if a muscular equinus condition exists
• Incorporate 2mm medial heel skives if the patient shoes excessive calcaneal eversion on weightbearing
• Incorporate plantar fascial grooves (mark these on the patient’s foot with lipstick before making the impression), if the patient presents with a prominent medial slip of the plantar fascia on dorsiflexion of the hallux
• Incorporate a deep heel cup if excessive calcaneal eversion is noted on weightbearing. (The heel cup depth should be greater than 14mm and up to 20mm, making sure that the heel counter of the shoe will allow the increased width that accompanies a deeper heel cup)
• Incorporate Morton’s Extensions if the patient presents with short 1st metatarsals
• Incorporate soft medial flanges in cases of extreme navicular drop on weigthtbearing, (making sure that the shoe can accommodate the increased width associated with this addition)

6. PLANTAR FASCIITIS HEEL PAIN
Typically caused by micro tears at the periosteal attachment of the medial slip of the plantar fascia at the medial calcaneal tubercle, leading to inflammation and pressure on the medial calcaneal branch of the tibial nerve. Symptoms may exist whether or not a heel spur is seen on radiological examination

Footwear Considerations:
• Firm, snug-fitting and deep heel counter in the shoe
• Shoe laces to be tightly secured (diabetics excluded)

Orthotic Considerations
Strongly Recommended:
• Order as high an arch profile as the patient will be able to tolerate (depending on the patient’s non- weightbearing arch height, degree of arch collapse on weightbearing, their age, activity level, level of tolerance to changes, etc.)
• Incorporate 3mm heel lifts (making sure the heel counter of the shoe can accommodate the increased height without the patient’s heel slipping during walking)
Optional:
• Incorporate 2mm medial heel skives if the patient shoes excessive calcaneal eversion on weightbearing
• Incorporate plantar fascial grooves (mark these on the patient’s foot with lipstick before making the impression), if the patient presents with a prominent medial slip of the plantar fascia on dorsiflexion of the hallux
• Incorporate a deep heel cup if excessive calcaneal eversion is noted on weightbearing. (The heel cup depth should be greater than 14mm and up to 20mm, making sure that the heel counter of the shoe will allow the increased width that accompanies a deeper heel cup)
• Incorporate Morton’s Extensions if the patient presents with short 1st metatarsals
• Incorporate soft medial flanges in cases of extreme navicular drop on weigthtbearing (making sure that the shoe can accommodate the increased width associated with this addition)

7. BUNIONS
This pathology known completely as “Hallux Abductovalgus” is identified by the following:
1. A medio-dorsal osteophyte in the 1st metatarsophalangeal joint
2. Abduction of the hallux towards the second digit
3. Valgus rotation of the hallux
The bunion deformity is caused by two prevalent factors must occur together for the condition to initiate and progress:
1. A genetic predisposition towards an adductus foot type, and
2. Abnormal subtalar joint pronation
Since the genetic predisposition is unalterable, the practitioner strives to manage the abnormal pronation in order to arrest the progression of the deformity. Arresting the abnormal pronation is a major factor in preventing the progression of the deformity but cannot reverse the deformity short of surgery

Footwear Considerations:
• Firm, snug-fitting and deep heel counter in the shoe
• Shoe laces to be tightly secured (diabetics excluded)
• Wide and deep toe box in the shoe to accommodate the deformity and possible digital deformities caused by the over/under riding of the hallux with respect to the second digit

Orthotic Considerations
Strongly Recommended:

• Order as high an arch profile as the patient will be able to tolerate (depending on the patient’s non- weightbearing arch height, degree of arch collapse on weightbearing, their age, activity level, level of tolerance to changes, etc.)
• Incorporate metatarsal pads to create a transverse arch support in the forefoot which serves to offload the metatarsal heads
• Specify additional cushioning in the forefoot to reduce shock related pain

Optional:
• Incorporate 3mm heel lifts if a muscular equinus condition exists
• Incorporate 2mm medial heel skives if the patient shoes excessive calcaneal eversion on weightbearing
• Incorporate plantar fascial grooves (mark these on the patient’s foot with lipstick before making the impression), if the patient presents with a prominent medial slip of the plantar fascia on dorsiflexion of the hallux
• Incorporate a deep heel cup if excessive calcaneal eversion is noted on weightbearing. (The heel cup depth should be greater than 14mm and up to 20mm, making sure that the heel counter of the shoe will allow the increased width that accompanies a deeper heel cup)
• Incorporate Morton’s Extensions if the patient presents with short 1st metatarsals
• Incorporate soft medial flanges in cases of extreme navicular drop on weigthtbearing, (making sure that the shoe can accommodate the increased width associated with this addition)

8. SHIN SPLINTS
Two presentations exist, either together or independent of each other:
1. Tibialis Anterior Shin Splints: Characterized by pain in the shins (anterior part of the tibia) during fast walking, running or maintaining paces on a treadmill. Abnormal pronation causes the subtalar joint axis to be displaced medially thus bringing it in line with the tibialis anterior tendon. As the muscle fires to clear the swing leg from the ground, it therefore has a minimal effect in supinating the subtalar joint and leads to micro tears in its periosteal attachment along the tibia followed by pain and inflammation in the region.
2. Tibialis Posterior Shin Splints: Characterized by pain in the anterior medial region of the lower leg, along the origins of the tibialis posterior muscle with the interosseous membrane between the tibia and fibula. Pain can be elicited during examination by deep palpation of the region. Abnormal pronation causes the tibialis posterior muscle to be ineffective during firing in re-supinating the subtalar joint, leading to tibialis posterior shin splints where micro tears in its periosteal attachment along its origins leads to pain and inflammation in the region

Of the two pathologies, Tibialis Anterior Shin Splints are easier to manage than Tibialis Posterior Shin Splints. For the posterior shin splints, maximal control against abnormal pronation is warranted, using ALL the control features outlined below. For the anterior shin splints, a moderate degree of control is sufficient and the severity of controls listed below may be reduced

Footwear Considerations:
• Firm, snug-fitting and deep heel counter in the shoe
• Shoe laces to be tightly secured (diabetics excluded)

Orthotic Considerations
Strongly Recommended:

• For the posterior shin splint condition, order as high an arch profile as the patient will be able to tolerate (depending on the patient’s non- weightbearing arch height, degree of arch collapse on weightbearing, their age, activity level, level of tolerance to changes, etc.) A moderate arch profile may suffice to treat anterior shin splints
• Incorporate soft medial flanges in cases of extreme navicular drop on weigthtbearing, together with additional arch pads in case of severe pes planus (making sure that the shoe can accommodate the increased width associated with this addition)

Optional:
• Incorporate 3mm heel lifts if a muscular equinus condition exists
• Incorporate 2mm medial heel skives if the patient shoes excessive calcaneal eversion on weightbearing
• Incorporate plantar fascial grooves (mark these on the patient’s foot with lipstick before making the impression), if the patient presents with a prominent medial slip of the plantar fascia on dorsiflexion of the hallux
• Incorporate a deep heel cup if excessive calcaneal eversion is noted on weightbearing. (The heel cup depth should be greater than 14mm and up to 20mm, making sure that the heel counter of the shoe will allow the increased width that accompanies a deeper heel cup)
• Incorporate Morton’s Extensions if the patient presents with short 1st metatarsals

9. PATELLOFEMORAL DYSFUNCTION
Two presentations exist, either together or independent of each other:
The common etiology of Patellofemoral Dysfunction is excessive tibial internal rotation which accompanies abnormal subtalar pronation. In addition to navicular drop (arch collapse) and calcaneal eversion, the tibia with its patella tendon attachment on the tibial tuberosity rotates internally excessively. This causes the patella to maltrack in the anterior femoral condoyls, ineffectiveness in the vastus medialis obliqus muscle fibres and an overpull of the vastus lateralis muscle leading to pain usually found in the lateral knee. The purpose of orthotic therapy is to limit the amount of tibial internal rotation by limiting the amount of pronation in the subtalar joint. The practitioner should be cautioned, however, that too much control in the orthotic device may lead to other painful symptoms in the knee joint, and the amount of control (especially in the height of the arch profile of the orthotic) should be monitored carefully. If in doubt, order the device with a moderate arch profile, and after monitoring the patient’s symptoms after intervention, this can be increased by external additions to the device.

Footwear Considerations:
• Firm, snug-fitting and deep heel counter in the shoe
• Shoe laces to be tightly secured (diabetics excluded)

Orthotic Considerations
Strongly Recommended:

• Order a medium arch profile, which can be increased externally if nescessary (depending on the patient’s non- weightbearing arch height, degree of arch collapse on weightbearing, their age, activity level, level of tolerance to changes, etc.)

Optional:
• Incorporate 3mm heel lifts if a muscular equinus condition exists
• Incorporate 2mm medial heel skives if the patient shoes excessive calcaneal eversion on weightbearing
• Incorporate plantar fascial grooves (mark these on the patient’s foot with lipstick before making the impression), if the patient presents with a prominent medial slip of the plantar fascia on dorsiflexion of the hallux
• Incorporate a deep heel cup if excessive calcaneal eversion is noted on weightbearing. (The heel cup depth should be greater than 14mm and up to 20mm, making sure that the heel counter of the shoe will allow the increased width that accompanies a deeper heel cup)
• Incorporate Morton’s Extensions if the patient presents with short 1st metatarsals
• Incorporate soft medial flanges in cases of extreme navicular drop on weigthtbearing, (making sure that the shoe can accommodate the increased width associated with this addition)


 
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Common Problems
  1. Achilles Tendonitis
  2. Calluses
  3. Morton's Neuroma
  4. Claw Toes
  5. Metatarsalgia
  6. Plantar Fasciitis Heel Pain
  7. Bunions
  8. Shin Splints
  9. Patellofemoral Dysfunction
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