Needs assessment/Consult
Do you live with lower limb pain and/or foot pain? Does this pain interfere with capacity for work demands, and just as importantly does pain interfere with recreational capacity and pursuit? If so, assessing mechanical, structural and functional baseline through the eye of an experienced Canadian Certified Pedorthist is a very good starting point. I use a very different lens than other physical medicine specialties.
Orthotics are FAR too often used as default pain management where other pain management modalities are not adequately working and/or adjunct management to a captive trusting audience. Pain can be the driver but where indicated, a true custom orthotic must come from rigorous specialty orthopedic assessment and be designed to manage structure and function in that relationships specificity for long term functional and structural gains. For more information regarding a consult please refer to “New Patients”.
Custom Orthotic Assessment
A custom orthotic assessment with me includes but is not limited to; a thorough history taking, including relevant medical history, a review of prior physical therapies at lower limb, their usefulness or lack thereof and possible suggestions for other specialty consultations. A footwear assessment/habits/choices and how these choices are suited to foot function and structural demand. A weight bearing and non-weight bearing assessment at lower kinetic chain and of course pre and post gait assessment. Occasionally where a custom orthotic is clinically indicated, management is put on temporary hold while we pursue further diagnostic tests and evaluation in order that we have all the information we need to allow us to create an appropriate custom device.
Side bar- for those runners/walkers "minimal footwear" is NOT suited to the masses and specialty consultation in any field recommending this exclusively and/or at all in many cases should be taken with a smile and caution. The initial, albeit slightly aged conversation around minimal running shoes became polarized from the outset, pushed to the far right by minimal footwear manufactures seeing an entire new industry and captive audience, by many specialty retailers seeing the very same thing, by physical therapy specialties carving new niches and management protocols to introduce to that injured active/captive audience. At the far left the naysayers dragged their opposition to an equally blinders on perspective. In the simplest way that I can summarize, there is NOT one sneaker category that suits all of us the same way. The injury history, the body type, the foot type in its structural and functional specificity and where that specificity falls on a runner/walkers timeline, leaves best suited in her or his active life span to perhaps 50 plus/minus running shoes to pick an entirely arbitrary number. Running/walking shoe types ranging from more minimal designs to more elevated options with more or less torsional stability and everything in between, that can be for the individual both independent and dependent upon where one falls on their timeline, etc. Function at lower kinetic chain is akin in some respects to a finger print; from where our center of mass sits, from angle from hip to knee and knee to foot, from orientation of the hindfoot to lower leg, from orientation of the hindfoot to midfoot, from orientation of the midfoot to forefoot and that to medial column and lateral column and to that position and range of motion at the great toe and lesser. Add to all of this varying degree of range of motion, from excessive in all planes to structurally insufficient in some or all planes, add to this possible injury history, add to this the runner or walker at 15 years of age, at 25 years of age, at 45 years of age at 65 years of age and you have one shoe category no more suited to the masses than tofu as a preferred staple for the masses. The idea that we should make a foot work to its maximal functional and structural capacity where the rubber hits the road, regardless of an individuals unique, mechanical structural and functional baseline, which is effectively what minimal management suggests, taking into consideration that “ training effect” and other, shows a limited understanding of the relationship between the foot and cumulative stress load at the bottom of lower kinetic chain. I will summarize and discuss what I believe to be the best of the research in future peer review. In summary for now, the point of this intentionally laboured side bar is simply to demonstrate some of the complexity of this conversation, a conversation that should not fall to polarizing and/or uninformed opinion or recommendation in clinical or retail settings.
The two trail running shoes to immediate left are radically different approaches to what could be the same trail on the same runner. The top shoe the Hoka Speedboat 2 has an enormous 32mm stack at heel and a 27.5 mm stack at forefoot with a 4.5 mm drop. Most runners would put this shoe at the more ‘maximal’ end of the running shoe spectrum despite the smaller drop heel to forefoot. The New Balance minimus trail on the bottom has a 14-15 mm stack at heel with a 4mm drop, putting this shoe at the more minimal end of the spectrum. Neither shoe fit into opposite ends of the spectrum proper ie., any drop is too much drop, any stack is too much stack etc. (The Hoka model is a current model new shoe, the New Balance option is an older iteration). Now a proper discussion and breakdown of the merits and pitfalls of both these shoes both of which are my shoes that I have tested on trails, could be fodder for a PhD thesis on biomechanics on the trail at lower kinetic chain….the point of inclusion here though out of twenty runners who will have more or less success with these two shoe options and why. Less success could include injury directly related to mechanical presentation and tolerance over time related to same. As sure as there are great trails there are lower kinetic chain finger prints that will have more of less success with these two shoe types. What is this observation based on and can we help runners and walkers figure that out? This discussion with video reviews will be continued.
Capturing the Positive Impression of the foot
I use the very latest technology in the industry to capture a three dimensional volumetric digital cast via a class one infrared laser camera of both feet. These 3D digital casts are taken in neutral subtalar suspension and uncompensated. For reference and for those who may have some experience with custom orthotics, prior to this technology I used wet plaster strips to take neutral suspension subtalar plaster casts of both feet. Every provider of true custom orthotics worth their weight will have a valuable opinion on how an impression of the feet should be taken in order to achieve repeatable, consistent, reliable and technically fixable results. I have worked with and have become very proficient over the years with all traditional means and some not so traditional. I consider this current means to be the most technically driven and although adjustments for misfits has been the lowest in all my years in practice, this technology allows me to identify that possible miss, digitally chase it down and resolve it to precise exacting degree and repeat it time after time.
Custom Orthotic Manufacturing
A pair of custom orthotics pre and post production
Once digital casts of both feet are taken and saved the scans are sent to who I consider to be one the most technically driven true custom orthotic lab in the country. The three dimensional scans are then digitally processed and alignment change and correction built into the digital three dimensional structure that will ultimately be reflected in the future orthotic shell. See image above. The picture to immediate left shows a robotic CNC machine creating a pair of orthotic shells from corrected three dimensional digital structure.
The image immediately below shows a softer shell type that has been vacuum pressed over high density foam casts that were also produced from digital three dimensional scans. In rare circumstance if a foot falls outside the suitability of infrared laser scanning, I am able to take plaster casts or even foam impressions and digitally process these and/or process by more traditional means. In other words my method(s) is entirely dictated by the specific need of the patient and NOT limited to my means.
The lab sends me the three dimensional Cad/Cam - CNC manufactured raw unfinished very early stage orthotic shells only, see soft example/bottom raw shell image immediate left. The shaping, carving, building, craftsmanship, finishing and adjustments/fixes all happen in my local private lab. Truly a marriage of the very latest orthopedic technology and a locally hand built medical appliance. NONE of this process constitutes an easy approach to custom orthotic process. What it does represent is an intention to provide to my patients the best true custom orthotic that I can, backed by cutting edge technology, hands on artisan craftsmanship and in house private lab service.
Adjustments are much less common than in the past and the need for a total orthotic remake is extremely rare, but if either are required there are never additional fees even long after a dispense date. Repairs, adjustments or other are managed immediately, local and typically the same day. The orthotics that I design and construct are built to last, some types for many years depending on the specific orthopedic requirement. Orthotic rebuilds are possible and encouraged, breathing in new life extremely affordably.
The partially finished orthotic shell to the immediate left and finished below, is made around a shell type referred to as semi-rigid and/or rigid polypropylene depending on need and can be tailored to meet specific orthopedic requirement and more generally for body weight ranging from under 40/50 lbs/27 kg to well over 300 pounds/136kg and can have affordable rebuild potential even after 4-5 years in service. This represents exceptional orthopedic value.
Orthopedic Bracing
UNDER CONSTRUCTION
