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Entering the Foot Zone:Training course
John O’Regan
Health, Safety & Housekeeping
• Toilets• Fire Exits and Assembly Points• Mobile Phones on Silent if not off• Tea & Coffee
Before we begin…
• Reference materials course booklet.• Shoes off and feet at the ready.• Open format – I will be offering a
podiatric/physiotherapy approach.
Course Objectives & OutcomesAt the end of the session(s), participants will be able to achieve the following:
• Assess Patients Confidently and Effectively using the 6 TestsTM.
• Identify any Limitations, Abnormalities or Conditions Impacting upon their Prescription of Foot Orthoses, when using the 6 TestsTM.
• Rationalise and justify the appropriate prescription and clinical application of foot Orthoses.
• List any contraindications, dangers & precautions.
• Confidently and appropriately issue, adjust and review foot Orthoses for a patient.
Introduction to Orthoses
Polyethylene vs. EVA Compression Moulded FoamFormthotics™ Polyethylene Foam• High grade proprietary thermoformable polyolefin closed cell
foams made specifically for Formthtoics™• Foam is firmer, more resistant to heat, and will hold a better
moulded shape longer and more accurately than an EVA.• Non-porous and flexible, lightweight, supportive, • Contains Ultra-Fresh™ - anti-microbial agent resistant to
fungi, mould, bacteria• Made in Christchurch, New Zealand since the 1970s• Mouldable at relatively low temperatures - 85 degrees• Re-mouldable any number of times
Page 7Foot Science I Name of Presentation
Formthotics™ 3D Milling Process
• Formthotics are 3D milled from a block of foam – ensures an even density of foam through out the orthotic
• Not heavily compressed in thin areas – as is the case with compression moulded products
Unique Tear Drop Shape• The base is not flat – the base of
Formthotics is 3D Milled
• Talo-navicular support or triplane wedge that is built into Formthotics
• Place where can most effectively alter the axis of the STJ
Formthotics History and Evidence
• Invented by a Sports Medicine practitioner Dr Charlie Baycroft and professional skier David Boyd in the 1970s
• Formthotics have treated millions of people around the world for over 35 years
• Manufacturing leader – first Automated Formthotics Machine (ATM) developed by Steve Gurney, circa 1988
• Today an established exporter - in around 25 countries supported by an established global community
• Proven. Supported by independent research. See www.formthotics.com/medical
Significant research about Formthotics
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Formthotics might be as effective as prescribed customised foot orthosesLandorf, K., Keenan, AM & Rushworth, L. (2001). Foot Orthosis Prescription Habits of Australian and New Zealand Podiatric Physicians. JAM Podiatry Med Assoc 91(4): 174-183.
Formthotics optimise plantar pressure distributionChia, J., Suresh, S., Kuah, A., Ong, J., Phua, J & Seah, AL (2009). Comparative trial of the foot pressure patterns between corrective orthotics, Formthotics, bone spur pads and flat Insoles in patients with chronic Plantar Fasciitis. Ann Acad Med Singapore; 38:869-75.
Formthotics treat Plantar FasciitisLandorf, K. & Keenan, M. (2006). Effectiveness of Foot Orthoses to Treat Plantar Fasciitis: A Randomized Trial. Arch Intern Med; 166:1305-1310.
Formthotics decrease back pain and lower limb injuryLarsen, K., Weidich, F., and Leboeuf-Yde, C. (2002). Can custom-made biomechanic shoe orthoses prevent problems in the back and lower extremities? A randomized, controlled intervention trial of 146 military conscripts. Journal of Manipulative and Physiological Therapeutics.25:5.p. 326-330.
Formthotics are effective in neuro-motor rehabilitation Kiruma Hiruma (Teikyo-University), Kayo Babano (Osaka International University). Effects of in-shoe thermoformed orthotic devices on static and dynamic balance.
6 Tests references
The Unilateral Forefoot Balance Test: Reliability and validity for measuring balance in late midlife women
Margaret S Clark, PhD, BAppSc(Physio) Research Fellow, Office for Gender and Health, Dept Psychiatry, Faculty of Medicine, University of Melbourne.
Using the Star Excursion Balance Test to Assess Dynamic Postural-Control Deficits and Outcomes in Lower Extremity Injury: A Literature and Systematic Review
Phillip A. Gribble, PhD., ATC,* Jay Hertel, PhD., ATC., FNATA., FACSM,† and Phil Plisky, DSc., PT., OCS., ATC‡
Normative Values for the Unipedal Stance Test with Eyes Open and Closed
COL Barbara A. Springer, PT, PhD, OCS, SCS¹; COL Raul Marin, MD¹; Tamara Cyhan, RN, BSN¹; CPT Holly Roberts, MPT, GCS¹; MAJ Norman W. Gill, PT, DSc, OCS, FAAOMPT¹Research Article
Development of Clinical Rating Criteria for Tests of Lumbopelvic Stability
Margaret A. Perrott,1 Tania Pizzari,2 Mark Opar,3 and Jill Cook4
1Musculoskeletal Research Centre, La Trobe University, Bundoora, VIC 3086, Australia
2 School of Physiotherapy, La Trobe University, Melbourne, VIC 3086, Australia
Formthotics™ technology
Variety of shapes and foam profiles
What are Formthotics? Custom Medical Orthotics that can be gently heated to mould to the exact shape of the foot and shoe in the clinic
Thermoformable
Page 13Foot Science I Name of Presentation
Before fitting After fitting
After 2 weeks
Flat Heel vs. Round Heel
• Formthotics rounded edge, deep heel cup
• Was the specific request of very experienced clinicians
• Gives a much more accurate result of fitting to their patients and their footwear.
• Allows the clinician to determine how Formthotics sit in the shoe.
• Unique to Formthotics Medical• Flat heel – may make it easier to fit
some shoes but does not allow for customization of positioning
What is an Orthosis?
Orthosis: (noun): “an orthopedic appliance used to Support, Align, Prevent or Correct deformities or to Improve the Function of moveable parts of the body”
Dorland’s Medical Dictionary
Orthoses are also referred to as: Orthotics Orthoses AFO’s TCI’s Arch Supports? Insoles? Any others?
A Foot Orthosis
• Is Not an Insole or Arch Support?
• Custom Made Therapeutic Device?
• Made for an Individual Foot?
• Incorporates the Therapist’s Expertise?
• Improves Foot and Leg Function?
• Effect can be Validated?
Efficacy of Foot Orthoses
“Foot Orthoses are effective but their mechanism of action is uncertain.”
Landorf, Karl B. and Keenan, A. Australian Journal of Podiatric Medicine Volume 32, Number 3, 1998
General Suggestions from various texts include:
• Patient Satisfaction 70 to 90%.• Good effect on pain, Plantar Fasciitis, Arthritis.• Alter position and motion of the foot and leg.• Change pressure patterns. • Foot Orthoses alter muscle activity & recruitment (Tib. Ant.).• Soft Foot Orthoses are as effective as hard ones.• Posts are not always required.
What do you think?
Root Theory model- a pathway for understanding morphology
Root Theory Model (1954 – 1966)› Basis was to classify normal & abnormal foot
types (osseous alignment).
› “Normal”/ideal foot alignment occurs when:
• Distal 1/3 of leg vertical
• Calcaneus vertical to supporting surface
• Plantar forefoot parallel to plantar rearfoot
• When in NCSP (also occurs during midstance period)
Variations from this “normal’ foot alignment (‘intrinsic foot deformities’) lead to abnormal foot function
“Making foot orthoses is more art than science and it is surprising that this model has
remained unchanged for so long”Dr Merton Root
Limitations to Root’s Model
› Single axis models
› Criteria for normal foot alignment
› McPoil et al (1988) - Only 17% of subjects had ‘normal’ foot alignment
› Reliability of measurement procedures
› Questionable interrater reliability for measuring deformities
› Lack of controlled trials on the effects of functional foot orthoses
Pronation V’s Supination
RigidMobile
StiffFlexible
ThinnerWider
ShorterLonger
HigherFlatter
Locks Mid Tarsal Joint (MTJ)Unlocks Mid-Tarsal Joint (MTJ)
Sequence of STJ Movement
Other Principles & Paradigms
The mechanisms by which orthoses bring about a change in the symptoms of patients is still widely unknown so all theories must be considered. Let us have a brief look at the following:
• The Tissue Stress Model• Neuromuscular Skeletal• Supination Resistance• Windlass Mechanism
Position of STJ axis
Medially deviated
Normal Laterally deviated
Net effect Pronation Neutral Supination
If the centre of pressure (generated from GRF) is located lateral to the STJ Axis the GRF will pronate the foot.
Tissue Stress Model
› Elastic properties of tissues
› Magnitude and direction of ground reaction force
› Oblique forces are harmful
› Foot orthoses alter Ground Reaction Forces
› Reduce force on the injured tissue
› Direct forces along the axis of the bones
Center of pressure
STJ axis
Ground Reactive Force
Neuromuscular skeletal› Preferred pattern of movement (centrally
processed and learned but capable of alteration)› Orthoses provide signal input to alter muscle
function ideally to allow lower limb to follow it’s assumed preferred movement activity
› Orthoses that support this path promote a more efficient locomotive pattern
A paradigm shift: The role of impact forces and foot pronationNigg 2001. Clin J Sports Med 11:2-9› Suggests that the effect of orthoses is neuromuscular
and there is an individual preferred path of movement that should be supported
› Devices which oppose this preferred path are uncomfortable and increase the loading on lower limb structures
Saggital plane The windlass mechanism
› The windlass mechanism occurs when dorsiflexion of 1st MTPJ tightens the plantar fascia and supinates the medial arch (identified in 1954 by Hicks)
› The windlass mechanism should occur when the swing leg passes the stance leg.
• Leg externally rotates, heel lifts and the foot supinates to create a rigid lever for propulsion
› Problems occur when timing is incorrect or force requirements are too high
Supination Resistance and the STJ axis
› Position of the axis has a direct correlation with the amount of force/effort required to supinate the foot during mid-stance
› The more medial the axis the more pronated the foot position
› The more lateral the axis the more supinated the foot position
Sagittal and transverse view of STJ axis
Lets Name Them!
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Degenerative Joint Disease
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Heel Pain
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Tendonopathies
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Reading The Foot - Practical
Osseous changes
Skin adaptations
Nail Changes
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6 Testsassessing foot & leg function
The 6 TestsTM
Test 1: Subtalar Motion Test
Test 2: Alignment Test
Test 3: Supination Resistance Test
Test 4: Jack’s Test (Windlass)
Test 5: Balance Test
Test 6: Forefoot Stability Test
Test 1: Subtalar Motion Test
STJ Neutral Position
• All joints have a Neutral Position• Resting idling or loose packed position• Maximally Congruent Surfaces• Minimal Tension• Able to move easily in either direction• Dynamically stable position• Restrictions alter the neutral position
Test 2: The Alignment Test
Closed Kinetic Chain
Changing the position of the subtalar joint changes the
alignment of the entire musculoskeletal system.
Test 3: Supination Resistance Test
Supination Resistance• Dr. Kevin Kirby 1984
• Craig Payne. Latrobe University, Melbourne, Australia
• Force required to lift the arch
• Average 138 Newton's
• Manual test is reliable
• Relates to the axis of the Subtalar Joint
Grading0- Very Low Resistance
1 - Low Resistance
2 - Moderate Resistance
3 - High Resistance
4 - Very High Resistance
5 - Impossible to Move
Test 4: Jack’s Test
Jack’s Test• Force required to activate the Windlass.
• Hicks 1954. Craig Payne 2004.
• Plantar Fascia winds around the base of the big toe.
• Average 62 Newton’s.
• Increased pressure in Plantar Fascia.
• The test needs to be performed to the point of full movement, unless no movement at all.
Test 5: Balance Test
Test 6: Forefoot Stability Test
Bringing it all together
6 StepsStep 1 - Formthotics selection and fittingStep 2 - Patient adjustment periodStep 3 - Rear foot modificationStep 4 - Forefoot modificationStep 5 - In-shoe testingStep 6 - Follow up and ongoing adjustment
Step 1 - Selection and fitting
• 6 Steps to create total contact foot orthoses
• Formthotics are moulded to the foot within the shoe
• Total contact orthoses provide neuromotor and mechanical facilitation
Step 1 - Selection
Considerations:› Patient pathology
› Patient activity
› Patient footwear
Patient centric decision making› Patient compliance
Careful selection and fitting results in customised patient management:› Neuromotor facilitation
› Biomechanical support
› Functional stability
› Reduce pain
› Unload damaged tissues to allow healing
› Dynamic guidance through gait
› Neuro muscular
› Proprioceptive
› Improve balance
› Comfort
Step 1 - Selection Select the Formthotics model and size Hard or soft foam?
Single or dual density?
Step 1 - Fitting› Carefully trim at the distal end if required. The
existing shoe liner can be used as reference.
› Fit into the shoe (after removing the shoe liner if present
Step 1 - Fitting
› Formthotics are heated in the shoe
› Formthotics are thermoformed (heat moulded) to the foot and footwear using the Formthotics Heating Machine.
› Formthotics and shoes are fitted to the patient and the patient stands
› Ideal foot position is approximated by having the anterior knee aligned over the second toe and knees are slightly bent.
54Formthotics Heating
Machine
Fitting and heating practical
Work in pairs and fit Formthotics to your partner.
› Select Formthotics› Fit Formthotics› Heat Formthotics
You choose: › Fit heated or › Fit at room temperature or › Both!
Step 2 - Patient adjustment period
Patient adapts to Formthotics› Build up time and activity
› 3 -7 days
› Formthotics form in accordance with the individual function and patterns of activity of the patient
› Enables patient’s body to adapt to the new position
Formthotics modification
Why pimp up Formthotics?!
Why do we customise?
› It’s case specific.
› To apply specific forces to the foot that will result in an improvement in pain or dysfunction.
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Hint: It’s not to match these shoes..
Step 3 - Rearfoot modification
Wedges apply a force to the rearfoot› Medially or laterally wedged
Medial wedging affects function:› Decrease supination resistance
› Decrease force for windlass
Lateral wedging affects function:› Decrease rearfoot supination
› Decrease rearfoot lateral instability
Rearfoot modifications include:› Medial/lateral rearfoot wedge
› Extended rearfoot wedge
› Heel raise
Step 4 - Forefoot modification
Wedges apply a force to the forefoot
Forefoot modifications include:› Lateral forefoot (valgus) wedge
› Metatarsal dome
› Metatarsal bar
› Medial forefoot wedge
› Kinetic wedge
› Dudley extension
› Cluffy wedge
Step 5 - In-shoe testing
Footwear effects foot and limb functionShoes and Formthotics work togetherOrthotic therapy may fail due to poor or inconsistent footwear
Functional in-shoe tests:› Alignment test
› Balance tests
› Gait analysis
Step 6 - Ongoing adjustment
Formthotics can be readjusted and remoulded any number of times.› Check every 3-6 months
› Monitor patient goals
› Measure patient outcomes
How to buy…
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www.pattersonmedical.co.uk
08448 730 035 [email protected]
Quote Promo CodeMR015
To get free heating machine worth £144
More Information
› Course handouts
› www.formthotics.com/medical
› You Tube – Fitting and product selection videos available
Thank You For Listening!
John O’Regan
