Accommodations can be applied to any custom orthotic, although restrictions apply due to material variables and manufacturing processes. Accommodations are classified as intrinsic if modifying the orthotic shell itself, or extrinsic if adding to the shell in the form of a cover or posting aspect.
Soft Spot – The lab makes a pocket in the orthotic shell where the practitioner has indicated. The pocket can be filled with Enduro to add padding and then covered. Quite often this accommodation is made for a protruding navicular bone in which case it is called a Fibroma bump and requires a medial flange.
Flanges – An extension of the medial or lateral aspect of the orthotic shell. The medial or lateral arch of the orthotic wraps up and hugs more of the foot, increasing control and allowing for the inclusion of intrinsic accommodations in this area. A medial flange is often prescribed for patients with severe pronation or adult acquired flatfoot. Lateral flanges are excellent for preventing the foot from sliding laterally off the orthoses, especially when the lateral flange extends all the way to the distal edge of the orthotic shell. The medial and lateral flanges are a critical aspect of a UCBL type device, often prescribed for pediatric patients and postoperative patients.
Lateral Clip – A Lateral flange which does not extend distally per usual. It extends only at the location of the calcaneus and cuboid.
Fascial Groove – A groove in the orthotic shell, parallel to the sagittal plane, accommodating the plantar fascia when it is protruding during dorsiflexion.
Intrinsic Heel Spur – A dell is created in the shell at the heel and then filled with a padded material such as Enduro..
Skives – A flat spot in the heel area of the orthotic shell. A medial skive creates additional resistance to pronation from heel contact though early midstance, similar to a rear foot post. Rapid pronators often benefit by combining a medial skive with a deep medial heel cup and a medial flare to the rear foot post. A lateral skive creates additional resistance to supination from heel contact through early midstance. Lateral skives are often prescribed for patients with lateral ankle instability, along with a deep lateral heel cup and a lateral flare to the post. Skives are a great option when the patient requires control from heel contact through early midstance, and yet has shoes that cannot accommodate a rearfoot post.
Heel Lift – Often prescribed for limb length discrepancies and equinus conditions, heel lifts are created by adding extra material to the heel posts. KLM recommends 6mm as a maximum for patients with normal shoes. Extra depth shoes allow for higher lifts, as well as full sole lifts which raise the heel, arch, and forefoot areas simultaneously. If shoe fit allows, a full sole lift is the best way to accommodate a limb length discrepancy.
Arch Fill – An addition of material on the plantar aspect of the medial or lateral arch with the intention of increasing the rigidity of the arch or increasing the amount of control the device can provide. Often added as an adjustment if the orthotic is bottoming out when the patient walks.
Arch Pad – An addition of padded material on the dorsal surface of the orthotic at either the medial or lateral arch simply to create more cushion in that region. KLM’s standard arch pad is 3mm or 1/8″ thick and made of Enduro. A medial arch pad is pictured below.
Medial Flip – An extension of the cover at the medial arch forming a structure comparable to a medial flange, although made of the soft cover materials instead of the rigid shell material.
Extrinsic Accommodations continued…
Forefoot Accommodation – A Forefoot Accommodation is added to the cover materials extending distal to the orthotic shell to offload sore, tender areas, IPKs, lesions, calluses, etc. The Lab creates a buildup of material around the area indicated by the practitioner which allows the specified area to float over a dell in the orthotic cover. When positioned at the first metatarsal to relieve bunion pain or treat Functional Hallux Limitus, this accommodation is also called a “Dancer’s Pad,” or a “Reverse Morton’s Extension.”
Morton’s Extension – A buildup of material beneath the first metatarsal head, distal to the orthotic shell. Often prescribed for structural hallux limitus and rigidus, or whenever motion at the first metatarsal phalangeal joint is not desired. The Morton’s Extension supports the first metatarsal head and hallux in relation to the second through fifth metatarsal heads and engages the windlass mechanism in late stance and propulsion.
Metatarsal Pad / Bar – Another very common addition to the cover materials of a custom orthotic, a metatarsal pad or bar, is an addition of padded material supporting the metatarsal heads. A metatarsal bar typically spans the entire width of the orthotic just proximal to the metatarsal heads whereas a metatarsal pad is a triangular pad placed most commonly directly proximal to the third metatarsal head. The metatarsal pad can come in various heights, widths, and can be placed in any specific location related to the metatarsal heads.
Neuroma Pad – Similar to a metatarsal pad, a neuroma pad is a more narrow and firmer addition placed between two metatarsal heads. This maintains a healthy separation between the metatarsal heads in question, which are typically getting pinched, thus disturbing the nerves between and causing a neuroma for the patient.
Heelspur Pad – An addition of padded material throughout the heel cup. Heel padding can be added to any orthotic to provide additional comfort to tender heels. They can also be shaped to offload pressure from a sore spot to the surrounding area with a horseshoe cut out or donut cutout, see below, both which are very effective for offloading heel spurs or pain from plantar fasciitis.
Horseshoe Pad – A heelspur pad shaped like a horseshoe.
Donut Pad – A heelspur pad with a circular cutout at the center of the heel.
Toe Crest – Made of korex or a similar firm material, a toe crest is added just distal to the metatarsal heads, and just proximal to the toes, creating a ridge of firm material for the toes to grip in the shoe. Often prescribed for patients with hammer toes.