Welcome to the Podiatry Arena forums, for communication between foot health professionals about podiatry and related topics.
You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members (PM), upload content, view attachments, receive a weekly email update of new discussions, earn CPD points and access many other special features. Registered users do not get displayed the advertisments in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!
If you have any problems with the registration process or your account login, please contact contact us.
The lesser digits are frequent sites of elevated plantar pressure and ulceration in the diabetic foot. We sought to determine whether debridement of callus and the wearing of a custom molded digital orthosis could significantly reduce digital plantar pressure. Fourteen patients with distal digital callus were studied. For each patient, the toe with the highest plantar pressure was selected. A computerized pressure mat was used to record the plantar pressure before and after debridement with and without a moldable silicone digital orthosis. Mean peak plantar digital pressures before treatment were 2.80+/-0.7kg/cm(2) for the entire group. The digital orthosis alone reduced plantar pressure to a mean of 1.95+/-0.65kg/cm(2)p<0.05. Treatment by debridement similarly reduced pressure to 1.99+/-0.76kg/cm(2)p<0.05. The most effective reduction of pressure for all patients, as well as the most statistically significant, occurred when both treatments were given, with mean peak plantar pressure falling to 1.28+/-0.61kg/cm(2)p<0.01. Debridement and custom molded digital orthoses alleviate distal digital plantar pressure. Since elevated plantar pressure increases the risk of neuropathic ulceration, these treatments should be considered in the prophylactic care of appropriate patients.
Thanks for this as I long been an advocate of silicone props (middle three toes) for pressure reduction management . Reassuring to see there is supporting scientific evidence .
Thanks for this as I long been an advocate of silicone props (middle three toes) for pressure reduction management . Reassuring to see there is supporting scientific evidence .
Cheers
Cameron
This is not the first article about toe props effects:
Effect of Orthotic Therapy on Claw Toe Loading
Abstract
This study demonstrates the effect of orthotic therapy for toe deformity on toe and metatarsal head pressures using a new analysis method facilitated by an in-shoe pressure-measurement system’s ability to export detailed data. Plantar pressure–time integrals in 11 individuals (22 feet) with claw deformity of the lesser toes were measured with and without toe props. Differences in pressure–time integrals at every individual sensor unit were then calculated for the two conditions, and significance was tested using the paired t-test. Plantar surface charts with contours of equal significant pressure–time integral change showed significant reduction under 17 second toes (77%), 22 third toes (100%), 15 fourth toes (68%), 13 second metatarsal heads (59%), 16 third metatarsal heads (73%), and 16 fourth metatarsal heads (73%). All 22 feet showed increases under the prop in the area of the third toe sulcus. This innovative approach to plantar pressure analysis could improve access to data that show significant pressure–time integral changes and, therefore, could advance the clinical application of plantar pressure measurement. (J Am Podiatr Med Assoc 94(3): 246–254, 2004)
Although, I prefer custom-made toe props instead of OTCs.
I have been using custom made three toe props (silicone putty) since the late seventies. I found the subtalar neutral manipulation an ideal reference position with which to apply the setting silcone to the three toes, leaving the plantar plane parallel to the three middle metatarsals. In essence these act as toe posts and set up a turning effect about the STJ when the heel lifts off the ground. Resistance against the proximal phalanx causes the plantar flexors to contract and there appears to be a resultant activity in the dorsal hood, causing the toes to straighten (sagittal plane). The abductory force through the silione medium (during take off) reduces its effects and the plantar interossei appear to re-engange toes 3 and 4, and they begin to pull towards the 2nd toe (trasverse adduction). These changes can be caught on the impression material and hence I use the devices in series (replaced every six weeks) with optimal non surgical straightening achieved in a 36 week period. Correction is dependent upon the quality and range of motion at the interphalangeal joints but even where there is osteoarthorosis present, marginal change in position reduces peak pressure over vulnerable skin areas.
Results from a linear reseach on RA patients (not published) demonstrated reduced incidence of lateral drift in subjects thought to demonstrate marked fibular deviation of the lesser toes due to the seriousness of their condition. Since then I have always used silicone props as a prophalaxis.
Cameron,
You said:
"I found the subtalar neutral manipulation an ideal reference position with which to apply the setting silcone to the three toes, leaving the plantar plane parallel to the three middle metatarsals. "
Ever since reading an article (I think written by your good self) in JBPM or The Chiropodist (can't remember how long ago, but it was a goodish time) about holding the foot in STJ-neutral when moulding the putty, I've done just that whenever one of these devices was needed.
I found that by using this method the silicone stayed in position more readily, and caused less chafing overall.
As you say, it's good to see some research to back up the theory - but in any case, the theory continues to work well :) !
Most probably like yourself I was influenced by Jim Black and always fascinated with the silicone orthodigital techniques he and Ian Coates developed in the 70s. I was never satisfied however with the arbitary way the props and slings were applied to the toes until I read about Root et al in the US. I thought if you put the two together and use GRF to activate the flexors and extensors then you would have passive traction and a universal reference positon to compare subsequent moulds. It seemed to work. So as a clinician I have much to thank the Californian's for ;-) but just don't tell them.
Who do you fancy for the final, England ? I see the Queen has arranged a meet in London in July
Cameron,
You're right. Jim Black and Ian Coates started it off for me too. I can't have been the only one around that time wondering why we were taught latex dipping technique, when silicone was around .
You said:
"It seemed to work. So as a clinician I have much to thank the Californian's for ;-) but just don't tell them."
:)
Then:
"Who do you fancy for the final, England ? I see the Queen has arranged a meet in London in July"
In essence these act as toe posts and set up a turning effect about the STJ when the heel lifts off the ground.
Hello Cameron,
I do not think so. It would happens if the foot would be a rigid body (lot of discussion about this topic in other threads). But, I agree that lesser toes should be on the same plane for better function.
I wonder if the art of manufacturing silicone ortheses is thought in other countries. In Spain have been thought since the early 80's and it is a very common treatment among podiatrists.
To jump in here, we have the silicone devices in Belgium as well. Even my all time favourite comes from around your corner being the Bland rose from fresco company. We have quite some hours of teaching on this subject, and is used a lot by podiatrists in Belgium.
interdigital corns, overriding toes, hamer- and clawtoes, ... protective, corrective or just consolidate...
There are some small unpublished works on the clinical effect of silicone props.
We were thinking of doeing some research on the effect of corrective silicone props on flexible hamer or clawtoes, but we couldn't really find some good measurement method to define the effect of the silicone devices. If someone has a hint on a reproductive and standard way of measuring the effect we could start something around this topic.
greetings
__________________
Ken Van Alsenoy
Artevelde hogeschool
dept. Podiatry
Ghent - Belgium
>I do not think so. It would happens if the foot would be a rigid body (lot of discussion about this topic in other threads).
Technically this would arise when the forefoot was locked against the rearfoot. We are looking at ms but it would happen.
>There are some small unpublished works on the clinical effect of silicone props.
There have been a couple of honours thesis in England (Northampton) and Finland (I believe). You should be able to locate these with a web search. My colleague Ian North (who subscribes) has done quite a bit of measuring the silicone moulds and may be able to add to this discussion.
Believe it or not I have tried to have papers published in Australia and the UK but these were rejected (obviously considered crap), but officially on the grounds that this technique was already standard practice in podiatry and no further value would acrue by publishiung case histories. Most odd and I do think there was a little bias involved, but who am I ?
If someone has a hint on a reproductive and standard way of measuring the effect we could start something around this topic.
greetings[/quote]
Kenva,
Further to Camerons comments we did some case studies in the mid 90's looking at reduction in flexible hammer toes with the use of serial silicone orthodigita. The assumption was that changes in the shape of individual moulds from a series represented changes in toe position. With experience in manufacturing the moulds and following a standardised reference position reproducible moulds were achieved.
At the time we used digital photographs vs standard vernier callipers to measure dimensions of the silicone moulds within the series to document change. Both inter and intra rater reliability was found to be acceptable.
I'd suspect now with scanning technology and suitable software more accurate measurement of the moulds could be acheived to document change.
Believe it or not I have tried to have papers published in Australia and the UK but these were rejected (obviously considered crap), but officially on the grounds that this technique was already standard practice in podiatry and no further value would acrue by publishiung case histories. Most odd and I do think there was a little bias involved, but who am I ?
How about orthotics research? I think that it is also an standard practice, or not?
Quote:
Originally Posted by Ian North
At the time we used digital photographs vs standard vernier callipers to measure dimensions of the silicone moulds within the series to document change. Both inter and intra rater reliability was found to be acceptable.
It would be the best approach. Today we have software tools for editing digital photos to vector graphics. Once you have a vector graphics you can calculate deviations and angles.
I've used Image J software before mainly for looking at weight bearing lunge test from digital photographs, but you might find it useful for the purpose of measuring the dimensions of silicone moulds and their contours ??? :)
After being taught this method by the great Cameron, I have been the most popular person in many old ladies' lives and they want to wrap me up and take me home!
I can only say that this is by far the most reliable method (custom made silicon props and debridement) to reduce a. pain and b. likelihood of apical ulcers.
Silicone orthoses and digital plantar pressures
.
Linear Mode
