The vast majority of variables are in the heel area. It is best to begin with the Heel Cup height.
Most labs choose their standard heel cup height based on gender and shoe type. Typically, men’s orthotics have a 12 mm heel cup and women’s have a 10 mm heel cup. This is because women’s shoes are usually less accommodating for orthotics. The higher heel cup has a tendency to lift the heel higher in the shoe and also makes the orthotic wider, making it difficult to fit comfortably in fashion or tight fitting shoes.
Most sport related orthotics have a 14 mm heel cup. Luckily, most sport and work shoes now have removable insoles, which provides more options that will increase control and not create shoe fit problems.
KLM’s standard is to measure the heel cup from the table to the posterior edge.
Medial Flanges are added to increase orthotic stiffness and pronation control. This is achieved by rounding up the medial aspect of the arch correction and shaping the device so that it wraps medially up around the first ray and talar/navicular (TN) area. Medial flanges are usually accompanied with a higher medial heel cup.
Medial flanges, however, can create shoe fit problems in adult shoes. And most adults cannot tolerate the additional stiffness and control. Medial flanges are used most often with children and are an integral part of a standard UCBL type device.
Also look for a TN bulge on your pes planus patients during mid-stance. You will need to accommodate it in the flange correction, creating a pocket to accommodate the TN bulge. It also helps to add a little padding in the pocket.
Lateral Flanges help prevent the patient’s foot from sliding laterally off of the orthotic and also resist unwanted supination during the stance phase of gait. Lateral flanges are usually accompanied with a higher lateral heel cup and especially useful for patients with increased transverse compensating mid-tarsal joints, and for increased medial-lateral control at mid-stance.
Lateral flanges also increase the bulk of the device and make it difficult to fit properly in most adult shoes. Lateral Flanges, like Medial Flanges, are typically used more for children and are an integral part of a standard UCBL type device.
Medial Skives involve flattening the heel area under the medial aspect of the positive cast, or mold, generating a corresponding flat shape on the orthotic under the medial posterior aspect of the calcaneus.
Medial skives create a supinatory moment from heel contact through the early stance phase of gait and thus create additional resistance to pronation, as with an inverted rear foot post. Studies have also shown that skives can be more effective than rear foot posts. Skives are also a great option when the patient’s shoes cannot accommodate a rear foot post. Combining an increased medial heel cup height with a medial flare on the rear foot post, and a medial skive are excellent options for heavy pronators.
A lateral skive causes a pronatory moment from heel contact through the early stance phase of gait and thus creates resistance to supination, much like a flat or everted rear foot post. Combining an increased lateral heel cup height with a lateral flare on the rear foot post, and a lateral skive are excellent options for patients who have a tendency for lateral ankle sprains.
A Forefoot accommodation will off load sore tender areas, IPKs, lesions, callouses, etc. A padded extension is added to the distal edge of the device that extends to either the sulcus groove or the end of the toes. Then another pad is added that has cut outs for areas that need to be offloaded. You choose the material, the durometer, and the thickness of both the extension and the cut out pad. Forefoot accommodations are often combined with a met pad to lift the metatarsal proximal to the area to be offloaded.
For patients with a large or tender styloid process on the base of the 5th metatarsal, order a Styloid Process accommodation. The lab will add additional expansion laterally around the base of the 5th met and also under it. The resulting orthotic will have a pocket for the Styloid Process to fit into comfortably. You also can add soft foam in the pocket to provide additional comfort.
Styloid process accommodations also are useful with patients who tend to subluxate the lateral column at the cuboid 5th metatarsal joint during heel off and into propulsion.
A Morton’s Extension is indicated for a structural elevatus of the 1rst ray, which causes the 2nd metatarsal head to bear weight excessively because the 1rst ray cannot plantarflex in late mid-stance and propulsion.
Its purpose is to preload the first metatarsal head and hallux and balance the load on the 2nd ray. Very useful for structural hallux limitus and rigidus, or whenever motion at the 1rst metatarsal phalangeal joint is not desired. The Morton’s Extension supports the 1rst metatarsal head and hallux in relation to the 2nd through 5th metatarsal heads and engages the windlass mechanism in late stance and propulsion.
A Dancer’s Pad or Kinetic Wedge is usually ordered to treat Functional Hallux Limitus.
Similar to a forefoot accommodation of the 1rst metatarsal head, the pad lifts 2 through 5 metatarsal heads, allowing the 1rst metatarsal to drop and function below the others, thus enabling 1rst metatarsal phalangeal joint dorsiflexion. Usually combined with a medial tip grind and a flat forefoot post to further allow the first ray and hallux to function below 2 through 5.
Varus or Valgus Wedges are added to carry the correction from the orthotic forward to the sulcus groove or the end of the toes. For example, if a 5 degree forefoot varus correction is added to the positive cast to invert the forefoot on the rear foot, this correction ends at the distal edge of the orthosis. Once the heel comes off the ground during gait, the correction is lost. So if rear foot control does not result in the medial column plantar-flexing during propulsion, undesired pronation will occur from heel off through propulsion.
Adding a 5 degree Varus Sulcus Wedge extends this correction beyond the distal edge of the orthotic and maintains the correction through heel off and propulsion. It is paper thin under the 5th metatarsal and up to 1/4 inch (6mm) under the 1rst metatarsal.
Similarly a Valgus Wedge is used to carry a valgus correction to the sulcus groove or the end of the toes. It is paper thin under the 1rst metatarsal and up to 1/4 inch (6mm) under the 5th metatarsal.
Valgus wedges are very effective for increasing 1rst ray stability and engaging the windlass mechanism.
Varus and Valgus wedges fill the toe box of the shoe and are only recommended for patient’s whose shoes have removable insoles. In addition, the amount of wedging available is limited by how much room is available in the toe box of the shoe.
Wear your orthotics for up to one hour the first day, two hours the second day and gradually more often if comfortable, or less if necessary. If your orthotics cause pain before you have worn them for the scheduled period, remove them. On the next day, Do not attempt to increase the wearing time. Then resume your schedule the following day, increasing the wearing period 1 hour per day.
You can also add Heel Lifts to rear-foot posts. Lifts are often added to the prescription for a limb length discrepancy. They also can be used to address a patient’s equinus condition, especially osseousis equinus or forefoot equinus.
Shoes with removable insoles allow you to elevate the heel in the shoe up to about 1/4 inch (6mm) and most labs recommend never going higher that. Extra depth shoes allow for even higher heel lifts, or lifts that raise the heel, arch, and forefoot areas of the foot simultaneously–which is the best way to accommodate a limb length discrepancy.
Metatarsal Bars (Met Bars) are pads that lift and cushion all five metatarsal heads simultaneously. Met bars are excellent for adding additional shock absorption at the metatarsal heads or for engaging the foot’s windlass mechanism.
You choose the material, the durometer, and the thickness of the Met Bar.
A tear drop build up on the dorsal distal portion of the foot orthotic that is highest in the middle and tapers away the edges. The met pad elevates specific metatarsal heads to reduce pressure on the met head. Standard met pad height is 1/8” and placed behind the third met head. They come in different sizes and thicknesses.
Both horseshoe cut outs and donut cut outs are very effective for offloading heel spurs or pain from plantar fasciitis. Most labs recommend no more than 1/8th inch (3mm) thick heel pads because they lift the heel higher in the shoe causing shoe fit problems. Also available is the intrinsic heel spur accommodation, pictured right, for which a delve is made in the shell and filled with a soft material.
A Toe Crest is ordered when you want to fill the sulcus groove. Toe crests can be ordered from soft materials such as poron and low durometer EVA foams, or from firm materials such as cork or high durometer EVA foams.
Toe Crests are very effective for stabilizing and supporting rigid or semi-rigid hammertoes. They often are used in combination with other special features to help stabilize the foot from heel contact through mid-stance and into propulsion.
Rear foot posts are usually added to resist and control heel contact pronation from heel contact through the early stance phase of gait. Posts are usually made from hard rubber or EVA foams. Many standard orthotics designs come with rear foot posts, such as most sports orthotics. Rear foot posts are also an excellent option for patients with a low subtalar joint axis, or whenever there is significant subtalar joint motion in the frontal plane.
The role of the Medial Arch Fill is to flare the medial edge of the orthotic away from the foot’s natural contour to allow for some flattening of medial arch. You can increase or decrease the medial arch fill on the positive mold based upon patient need.
Increasing the arch fill will lower the medial arch height of the orthotic and allow the foot to pronate more on the device. This can be especially helpful for older patients or obese patients who cannot tolerate full correction.
Decreasing the arch fill will raise the medial arch height on the orthotic, allowing for a closer fit to the foot’s medial arch and provide more control of pronation and the foot in general—most often used for kids, young adults, and athletes.
Thus, the height of the arch directly affects the stiffness, or rigidity, of the orthotic shell. See the arches below. Both have the same width and thickness. The higher arch will be stiffer or more rigid because of the increased curvature. This rule applies to all spring like arches.
Clinical pearl: by ordering less Medial Arch Fill, you can get the same stiffness out of an orthotic from a thinner plastic plate, or a more flexible composite weave. By ordering more Medial Arch Fill, you get a more flexible (less stiff) orthotic.
The purpose of the Lateral Correction is to account for fat pad expansion along the heel and lateral border during weight bearing. Typically added to non weight bearing casts or digital scans.
So it is important to identify patients with excess fat or who lack tissue tone in the heel area, when considering how much lateral correction to request. Excess fat add more. Lack of fat tissue, add less.
Yes! All KLM Products come standard with a 6 month guarantee. The guarantee protects against defects in materials and workmanship. Only Uniflex devices have a lifetime guarantee against breakage of the orthotic shell. Unfortunately, KLM cannot issue credit due to patient non-compliance, non-tolerance, non-acceptance, or reimbursement failures. Adjustments to orthotics are covered within the first 6 months; for example, adjusting arch heights or shortening orthotics. Changes to the original prescription are not covered. For example, adding an accommodation that was not originally requested or changing the orthotic type is not covered.
Yes! KLM’s Extended Warranty is available for purchase up to 60 days after the date the orthotics are delivered to the footcare professional. Signing up is easy. The patient simply fills out the Orthoshield Extended Warranty Program application form and returns it to KLM Labs with a check or money order for $100. The warranty is active for 2 years from date the footcare professional receives the orthotics. The program covers four areas:
- The cost of any adjustments the doctor thinks are necessary.
- The replacement of any lost or stolen orthotics. (A $50 per foot surcharge is applied on each such claim.)
- The replacement or repair of any damaged or broken orthotics (A $50 per foot surcharge is applied if damaged devices are not returned to KLM Labs.)
- A free second pair of orthotics per contract is available for patients between ages 1 and 15. Young, growing people often outgrow their orthotics in two years. The patient can simply return the old orthotics to the doctor, and we will make a new pair at no cost. The warranty covers lab costs only. It does not cover doctor’s fees or office visits. In effect, this Extended Warranty Program covers all problems with orthotics for two years from the delivery date to the doctor. The program protects the patient against virtually all unforeseen difficulties.
Due to the hands on labor required to construct custom orthotics, quantity discounts are not available. However, KLM has devised multiple ways of reducing the labor and cost of orthoses. Historically, custom neutral position orthotics were made by converting the negative casts of a patient’s feet into positive plaster molds. The orthotics were then pressed to the corrected molds to create a handmade custom device. This technique is known as “Hand Corrected” and is the most labor intensive way to make custom foot orthotics, also making it the most expensive. The innovators at KLM Labs developed another technique called “System_Rx.” This computerized cast correction system uses the critical data from the patient’s negative casts. Per the practitioner’s prescription, corrections are added and the computer generates a positive mold to which the custom orthotic is pressed. Removing some of the labor required for the Hand Corrected technique, System_Rx allows for reduced costs without compromising accuracy. KLM Labs has expanded on the “System_Rx” correction technique by creating the “Value System_Rx” orthotic shells. After monitoring System_Rx and discovering that 99 shapes repeated themselves more than 70% of the time, KLM built these 99 shapes as plastic injection molds. Now these common shapes can be injection molded as polypropylene shells available in 3 rigidities. While these shells are not recommended for patients with severe foot deformities, they are very effective for patients with normal foot types. The less labor required to make the orthotic shell, the greater savings for the practitioner.
Bunion – Break down of first metatarsal joint, which causes the first toe to drift in and under the second toe and the first metatarsal to drift medially, creating a< shape along the medial aspect of the foot. Bunions are caused by over pronation.
Calcaneal Apophysitis – Inflammation of tissue around calcaneus in growing children.
Charcot Marie-Tooth – Degenerative muscle disease that deforms foot.
Clubfoot – Deformity. Usually affects one foot, creating feet of different sizes.
Crepe Arch Fill – A plantar fill of crepe material applied to the plantar surface of the foot orthotic to increase orthotic rigidity and reduce foot orthotic flexibility.
Drop Foot – Condition where foot hangs in plantar flexed position and cannot lift or dorsiflex at all.
Equinus – Short Achilles Tendon. Patient cannot dorsiflex normally. Solution: Stretching program or TAL. Sometimes use heel lift for orthotic.
Fascial Groove – A delve or out bump from the dorsal to the plantar aspect of the foot orthotic that accommodates a tight halucious longus tendon.
Genu Varum – Bowlegged.
Genu Valgum – Knock-kneed.
Hallux Limitus – Structural — 1st met less than 10 degrees of motion causing limited motion of 1st met shaft. Functional — 1st met less than 10 degrees of motion, however, in neutral position the patient’s hallux exhibits normal range of motion.
Heel Lift – A build up under the plantar rear foot post to equalize the leg length discrepancy. A rear foot post is required and a heel lift should not be greater than 6mm for shoe fit purposes.
Heel Spur – Extremely painful bone spur on the bottom of the heel (plantar calcaneus). Caused by excessive pronation over long periods of time.
Heel Spur Accommodations –
- Donut – 1/8” Enduro pad on dorsal heel of the foot orthotic with a circular hole cut out of the center of the pad.
- Pad – 1/8” Enduro pad on dorsal heel of the foot orthotic.
- Horseshoe – 1/8” Enduro pad on dorsal heel of the foot orthotic with a cut out of the center of the pad from the center of the heel distally to the end of the pad. Shaped like a horseshoe.
- Intrinsic – (Soft Spot) – A delve or concave bump from the dorsal to the plantar aspect on the foot orthotic at the center of the heel that is filled with Enduro to create a soft accommodation. Least bulky of all the heelspur accommodations.
IPJ – Interphalangeal Joint. The joint between bones in the toes.
IPK – Intractable Plantar Keratoma. A callous that won’t go away.
Lateral Clip – The foot orthotic’ s lateral aspect is contoured only at the calcaneal cuboid joint to prevent the foot from sliding laterally off the foot orthotic.
Lateral Flange – The foot orthotic’ s lateral aspect is contoured around the foot to prevent the foot from sliding laterally off the foot orthotic.
Lateral Heel Skive – The plantar lateral heel area of the positive cast is “flattened” to create a valgus wedge effect within the heel cup. This causes the center of the force that the orthosis is applying to the heel to shift laterally, increases pronatory torque, and acts to limit inversion or encourage eversion of the rear foot on the orthosis. This modification is useful when treating pathologies caused by excessive supination such as lateral ankle instability, pes cavus and medial knee osteoarthritis.
Medial Heel Skive – The plantar medialheel area of the positive cast is “flattened” to create a varus wedge effect within the heel cup. This causes the center of force that the orthosis is applying to the heel to shift medially, increases supinatory/pronatory torque and stabilizes or inverts/everts the rear foot on the orthosis.
Medial Flange – The foot orthotic is made wider medially and contours the medial arch of the foot more to increase pronation control.
Metatarsal Bar – A buildup on the dorsal portion of the foot orthotic that is designed to transfer force off of the metatarsal heads and onto the metatarsal necks and shafts. Standard met bar height is 3mm.
Metatarsal Pad – A tear drop build up on the dorsal distal portion of the foot orthotic that is highest in the middle and tapers away the edges. The met pad elevates specific metatarsal heads to reduce pressure on the met head. Standard met pad height 1/8” and placed behind the third met head.
Metatarsalgia – Pain under the forefoot or ball of the foot.
Morten’s Extension – 1/8” build up under the 1st metatarsal.
Neuroma – Nerve problem creating pain between the metatarsal heads. Caused by pressure from surrounding metatarsal heads.
Plantar Fasciitis – Arch pain caused by stretching or tearing of plantar fascia. Usually the result of over pronation.
Sesamoid Accommodation – 1st metatarsal accommodation that offloads the sesamoids.
Soft Spot – A delve or concave bump from the dorsal to the plantar aspect on the foot orthotic that is filled with Enduro to create a soft accommodation for a tender area of the foot.
Toe Crest – A 1/8” plastizote build up on the forefoot extension of the top cover that supports the toes in the sulcus groove.
Intrinsic Forefoot Post – Plaster correction added to the positive foot model that balances the forefoot to the rearfoot.
Extrinsic Forefoot Post – Crepe material added to the distal edge of the orthotic that balances the forefoot to the rearfoot.
Intrinsic Rear foot Post – Achieved by grinding the plantar heel of the foot orthotic.
Extrinsic Rear foot Post – Achieved by adding a crepe material to the plantar heel of the foot orthotic.