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Prolab in their latest Orthotic Communique have some interestig snippets of advice:
Quote:
Improving Orthotic Outcomes with Casting
Do you critically evaluate your orthotic outcomes? Are some of your timesaving steps negatively impacting your outcomes? Proper negative casting can affect orthotic outcomes. Take a moment to consider small changes in your casting and cast preparation that may improve your orthotic therapy success:
- Plantarflex the 1st ray to its end range of motion (ROM) when casting to increase 1st MPJ dorsiflexion and decrease 2nd metatarsal pain
- Cast the foot "loaded" (dorsiflexed to the end of its ROM) to assure optimal position of the foot on the orthotic during weightbearing
- Evaluate the negative cast to assure that there was good contact with the plantar surface and that the foot was not in an abnormally pronated or supinated position
- Place the cast on a table to determine whether you have captured the foot's forefoot-to-rearfoot relationship. Compare the foot and the cast to ensure that they match.
- Mark the "problem" areas on the casts as well as on the prescription form. This will assure that sweet spots, plantar fascial grooves (PFG), and other accommodations are placed correctly. Don't oversize the markings for the lesions or hot spots.
Remember, a great cast is the first step to great orthoses.
Evaluation of negative cast: i) External cast evaluation: a) Overall
1) Does the shape of the cast capture the shape of the foot? b) Contour of plantar aspect:
1) Is the cast smooth on the posterior and plantar heel?
2) Is the cast smooth on the plantar forefoot?
3) Is the cast smooth in the midtarsal joint area?
4) Is the plaster strong plantarly? c) The thumb print:
1) Is it placed laterally?
2) Is there any distortion proximal to the 4th and 5th toes?
3) Any distortion on the lateral side of the 5th metatarsal head?
4) Is the lateral border of the foot straight? d) The lateral view:
1) Is the 5th toe straight?
2) Is the plantar aspect of the 5th metatarsal prominent?
3) Is there a smooth curve in the area of the calcaneocuboid area? e) The medial view:
1) Is the hallux straight?
2) Is the first metatarsal head prominent?
3) Is the area at the height of the mid-arch smooth? f) The posterior view:
1) Is the folding of the plaster about the heel neat?
2) Does the cast capture the heel morphology?
3) Is there sufficient height for an accurate heel bisection to be made? g) The anterior view:
1) Did the cast contract the toes?
ii) Internal Cast Evaluation: h) Overall:
1) Is there a smooth contact of plaster to the skin? i) Distomedial:
1) Is there a good impression of the first metatarsal?
2) Is there an absence of large wrinkles?
3) Is there a good contour and elevation of the arch towards the heel? j) Distolateral:
1) Is there an absence of large wrinkles?
2) Is there a similar curvature to the medial side? k) Transverse plane:
1) Do the skin lines appear straight?
2) Is the lateral column straight? l) Frontal plane:
1) Is there the 1/3rd to 2/3rd relationship between medial and lateral? m) Heel:
1) Is there a good capture of the sustentaculum tali area?
2) Is the definition of all heel borders good?
3) Are the medial and lateral borders of the heel strong?
4) Is the curvature from the heel to the cuboid smooth?
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
Last edited by Admin : 30th March 2006 at 02:56 AM.
Is there a guideline to the position of where the lateral thumb print should be? and why?
Is it on the 5th met head,
Is it on de 4th and 5 met head
Is it just proximal from the 5th or 4/5th
maybe others
We take our prints behind the 4/5th met head because direct pressure on the 5th met head would influence the FF-RF relationship... There is more soft tissue right behind the met heads.
anyone some advice?
tnx
Ken
__________________
Ken Van Alsenoy
Artevelde hogeschool
dept. Podiatry
Ghent - Belgium
Do you critically evaluate your orthotic outcomes? Are some of your timesaving steps negatively impacting your outcomes? Proper negative casting can affect orthotic outcomes. Take a moment to consider small changes in your casting and cast preparation that may improve your orthotic therapy success:
- Plantarflex the 1st ray to its end range of motion (ROM) when casting to increase 1st MPJ dorsiflexion and decrease 2nd metatarsal pain
- Cast the foot "loaded" (dorsiflexed to the end of its ROM) to assure optimal position of the foot on the orthotic during weightbearing
- Evaluate the negative cast to assure that there was good contact with the plantar surface and that the foot was not in an abnormally pronated or supinated position
- Place the cast on a table to determine whether you have captured the foot's forefoot-to-rearfoot relationship. Compare the foot and the cast to ensure that they match.
- Mark the "problem" areas on the casts as well as on the prescription form. This will assure that sweet spots, plantar fascial grooves (PFG), and other accommodations are placed correctly. Don't oversize the markings for the lesions or hot spots.
Remember, a great cast is the first step to great orthoses.
Could someone explain to me how one can plantarflex the 1st ray to end of ROM without introducing a greater FF valgus? When the cast is placed on the table (as suggested) it is more likely to sit more inverted than the measured FF valgus, is it not?
This is how I used to cast with, at times, very unpredictable results - I now blame the increased valgus FF. Presently, I plantarflex the 1st and 5th rays, as per discussions with Bruce Williams and must admit the overall results, both comfort and effectivnes of the resulting orthoses, have greatly improved. It seems to me that by pl-flexing the 5th ray the increase in valgus position is not as drastic, thereby more closely resembling the FF to RF position.
Any tips for negative casting that increase the comfort of the high arched foot?
Also why do I often find that when I take a truly representative cast of a substantial 'inverted' forefoot to rear foot position, that has resulted in a large relaxed rear foot valgus stance position - I get an orthotic that often fails to adeqately correct the problem? How can I improve my casting to avoid this? or is it all in the prescription?
Any tips for negative casting that increase the comfort of the high arched foot?
Get the lab to add a large plantar fascial groove in the shell.
Quote:
Also why do I often find that when I take a truly representative cast of a substantial 'inverted' forefoot to rear foot position, that has resulted in a large relaxed rear foot valgus stance position - I get an orthotic that often fails to adeqately correct the problem?
Sounds like you not casting out the forefoot supinatus. Plantarflex the first ray and/or dorsiflex the hallux during casting.
Dear All,
I am interested in your casting technique when applied to a child with a medially deviated STjt axis and joint hypermobility is present.
How do you load the forefoot without pronating the STjt or creating abduction at the MTjt?
The reason I ask, is that I tend to stabilse the calcaneus and prevent navicular drift whilst loading the forefoot.
What say you??
regards
Tony
Just to add to Tony's piece, how do you cast a foot, without creases in the cast, whilst plantarflexing the 1st ray, loading the 4th/5th met (not to mention plantarflexing the 5th ray if this is what some people are doing), whilst, as Tony says, preventing a STJ pronated position and, therefore, navicular drift? I'm afarid I've run out of hands!
I've had loads of difficulties casting hypermobiles or other difficult feet whilst trying to fit all these other bits in! Especially if the width if the foot is larger than the capabilities of my hands (typical woman!)! I feel that it is leading to more problems in some cases and have taken to only plantarflexing the 1st ray when it is definitely needed as in tib post dysfunction patients.
Instead I have been putting 1st ray cut-outs into the ones that need more Hicks windlass, espcially runners, which has done brilliantly (so long as there's enough proximal valgus support).
How can you plantarflex the 1st and 5th rays, whilst maximally dorsiflexing the ankle and mimicking load-bearing anyway?! Perhaps someone could video themselves doing this and post it on the site?
This debate on casting the foot is really intriguing!
'Just to add to Tony's piece, how do you cast a foot, without creases in the cast, whilst plantarflexing the 1st ray, loading the 4th/5th met (not to mention plantarflexing the 5th ray if this is what some people are doing)'
It occurs to me that if you have a large forefoot supinatus and you plantarflex the 5th ray as well as the 1st you will then recreate the original position? How can this help to 'cast out' the supinatus?
"It occurs to me that if you have a large forefoot supinatus and you plantarflex the 5th ray as well as the 1st you will then recreate the original position? How can this help to 'cast out' the supinatus?"
Not really sure why you would wish to plantarflex the fifth ray
You are absolutely right that plantarflexing the 1st ray will create creasing of the skin. To prevent this, it is possible to dorsiflex the hallux, gaining reciprocal plantarflexion of the 1st ray, although I find this difficult when controlling the rearfoot personally.
I feel it also inportant to mention that 1st ray plantarflexion effectively raises the height of the medial arch, which needs to be taken into account.
Again I feel this can be useful as it can increase the supination moment of the orthotic.
regards
Tony
Your right if you plantarflex the 1st mpj when casting you may in some situations pf the 1st abnormally. In my mind the only time I plantarflex the 1st is when I have a f/f supinatus or met primus elevatus and dont want my device to be incorrectly posted as usually the f/f-r/f will decrease when you reduce the pronatory force on the hindfoot.
If you've taken a nice cast look at the prescription.Minimal arch fill,+4 degree varus rearfoot post,medial skive,medial flange,rigid shell construction proximal arch,thin distal arch,1st met cut out.
It's all about shifting force laterally,try these measures.
A lot of talk about plantarflexing thr 5th ray here which is difficult unless you have an assistant,why not just instruct the lab to remove some of the plaster from the lateral-plantar border instead.
Just to add to Tony's piece, how do you cast a foot, without creases in the cast, whilst plantarflexing the 1st ray, loading the 4th/5th met (not to mention plantarflexing the 5th ray if this is what some people are doing), whilst, as Tony says, preventing a STJ pronated position and, therefore, navicular drift? I'm afarid I've run out of hands!
I've had loads of difficulties casting hypermobiles or other difficult feet whilst trying to fit all these other bits in! Especially if the width if the foot is larger than the capabilities of my hands (typical woman!)! I feel that it is leading to more problems in some cases and have taken to only plantarflexing the 1st ray when it is definitely needed as in tib post dysfunction patients.
I'm not sure that all these moves are necessary. Take a reasonable cast, use a good lab, don't worry if you have to do some post-fitting mods. I'm sure we all have to do this from time to time.
With hypermobile feet I find it helps to place a couple of fingers (of the free hand) on the navicular.
I often find (when teaching others to cast) that basics, like good plaster control, have been overlooked. Casting need not be messy
But for me the essence of a halfway decent cast is, "does it resemble the foot?" and "can I see a FF to RF difference?"
Regards,
Davidh
(world's worst caster :) )
Is there no consensus on that thumb print of mine? We're talking about plantar flexing the 5th ray/1st ray...
is there any literature on what cast-adaptations to make in certain pathologies? Here and there you can find something (if they aren't contradictory) but no key-reference...
tnx
__________________
Ken Van Alsenoy
Artevelde hogeschool
dept. Podiatry
Ghent - Belgium
This may have been covered elsewhere (& yes, I have looked but can't find). The majority of forefoot varus deformities are a supinatus. And I gather from what I can find, this should be corrected when casting? Is that correct? If so, is this acheived by plantarflexing the 1st ray only or attempting to almost I guess rotate the forefoot down to balance the rearfoot. Probably dum questions to many of you.
Improving casting
push,push it out!!!!!!!!!!!!
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