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The latest newsletter from Larry Huppin at ProLab was about Where Should the First Ray be When Casting for Orthoses?:
A stable foot position during gait and a full range of motion (ROM) of the great toe joint are dependent on the first metatarsal remaining in a plantarflexed position during midstance. The only way to acheive this is to ensure that the first ray is plantarflexed when taking the negative cast.
Creating a negative cast for orthotics with the first metatarsal in any position other than plantarflexion will encourage first ray hypermobility. This causes foot instability during midstance and contributes to foot pain in the medial arch area of the orthosis.
Make sure that you evaluate your negative cast before the patient leaves the treatment room, to ensure that you have captured the foot in the correct position. The hallux of the negative cast should always look slightly dorsiflexed when the cast is placed on a flat surface.
Attention to the position of the first ray during casting is essential to the fabrication of the most effective and comfortable functional orthoses.