Chapter

3
Rational
Prescription of Foot
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and Ankle Orthotics

Orthotic prescription mirrors expertise of a specialist!

Orthotic prescription should have logic and rationale. Consideration of a few simple
points will make a prescription perfect.

Criteria for Prescribing Orthotic or Shoe Modification

Criteria for orthotic prescription are listed in Box 3.1.
Age of the patient: A young and active patient would need stronger and durable
material. These orthotics need to be slim in order to be easily accommodated in
the shoe. Orthotics for female patients must take care of cosmetic aspects. In the
older age group, associated comorbid conditions, poor vision, presence of arthri-
tis, and issues of balance are of prime consideration.

Box 3.1 Criteria for orthotic prescription

Age of the patient

Activity level of the patient
Type and location of deformity
Status of sensations in foot
Bony prominences and ulcers
Study and analysis of existing orthotics
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 52 Chapter 3

Activity level of the patient: Activity level has a direct bearing on the wear and
tear of orthotics, which needs repetitive check-ups, changes, and replacements.
Type and location of deformity? Is the deformity rigid or flexible? Complete descrip-
tion of deformity is needed. Flexible deformity needs corrective orthotics, while a
rigid deformity needs accommodative orthotics.
Status of sensations in foot: An impaired sensation in the foot requires special care
to make sure that there is no pressure from orthotics. Repetitive examination by
patient, consultant, and orthotist is required to ensure proper fit of orthotics and
lack of any pressure on an insensate foot by orthotics.
Bony prominences and ulcers with its location and details: Drawing of bony promi-
nences or ulcers on a paper is advisable. Locations with depth or prominence are
noted. Amount of discharge from ulcer is specified to judge the need for space for
dressing material.
Study and analysis of existing orthotics or shoe modifications: Wear and tear of
existing orthotic/shoe would give an idea about usage, habits, and hygiene of the
patient. It is advisable to send all previous orthotics/shoes to an orthotist for study
before preparing a new one.

Formulation of an Orthotic/Shoe Modification

The key is to get answers to the following questions:
Why do I want orthotic or footwear modification in this patient? What objectives
should it fulfil? Objectives could be any one of the following:
Reduce the impact and improve shock absorption
Relieve the pressure over sensitive structures
Correct the flexible deformity
Accommodate the fixed deformity and compensate for reduced movements
Provide support and maintain the neutral position
Limit abnormal or excessive movements
Does this patient need custom-molded orthotics or would a prefabricated orthot-
ics work?
Presence of deformity and abnormal shape and size of foot would mandate the
use of custom-molded orthotics.
Any other specific factors to be considered? Age, activity level, cosmesis, and sen-
sations are the factors to be considered.
Table 3.1 gives details of various foot and ankle conditions and commonly prescribed
orthotics or shoe modifications for them.

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 Rational Prescription of Foot and Ankle Orthotics 53

Table 3.1 Conditions and common orthotic prescriptions

Foot and ankle Goal Prescribed orthotics/shoe modifica-

problems tions
Hallux valgus Align first ray Night splint
Offload first metatar- Toe spreader
sophalangeal (MTP) joint Gel pad inside shoe/insole
Rocker bottom shoe/insole
Carbon fiber insole
Hallux rigidus Total plantar surface con- Silicone gel sleeve
tact to reduce load over Low heel, high toe crest footwear
first MTP Rocker bottom shoe
Carbon fiber insole
Hammer, claw, Total surface bearing Flexible:
and mallet toes Stress-free toe tip Metatarsal bar
Stretching of shortened Night splints
extensors Rigid
custom-molded total contact orthosis
Toe crest pad
Morton Offload painful neuroma Silicone gel pad
neuroma site Metatarsal pad
Carbon fiber foot plate
Metatarsalgia Maintain parabolic arch Metatarsal arch pad
of foot Carbon fiber foot plate insert
Total contact orthosis
Plantar corn/ Take pressure off the pain- Offloading pads
callosity ful area Scalloping inside insole
Silicone gel pad
Flat foot—stages Arch correction Valgus pads with C and E heel
1 and 2 Deformity prevention UCBL
Supramalleolar orthosis
Flat foot stage 3 Accommodation of Total contact foot orthosis/insole
deformity Foot mold orthosis
Heel varus Maintaining subtalar joint Lateral/outer heel wedge
to neutral Reverse C and E heel
High wall UCBL
Pes cavus Minimizing foot fatigue Custom-molded total contact foot
with total surface contact orthotic
Midfoot arthritis Arrest progression of Supramalleolar orthosis
deformity Short ankle–foot orthosis (AFO)
Take load off painful site Longitudinal firm arch support
Plantar fasciitis Relieve load over inflamed Silicone heel cushion
fascia Scooped heel
Arch support

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 54 Chapter 3

Table 3.1 Conditions and common orthotic prescriptions (Contd.)

Foot and ankle Goal Prescribed orthotics/shoe modifica-

problems tions
Retrocalcaneal Release tension on tendo Heel raise/lift (minimum 3 cm)
bursitis, inser- Achilles Silicone heel (donut shape)
tional tendinitis
Foot drop Prevent gravitational drop- Toe-raising splints
ping of foot Dynamic AFO
Assist in gait Static AFO
Charcot neu- Stabilization of foot Charcot restraint orthotic walker
roarthropathy (CROW)

Model for Orthotic/Footwear Alteration Prescription

An exemplary model for orthotic prescription is explained in Fig. 3.1.

Name of the patient:

Age: Occupation:
Diagnosis:
Sensations:
Deformity/Ulcer:
Foot drawing:

Aim of orthotic/footwear modification:

Shock absorption/ Pressure relief/ Deformity correction/
Deformity Accommodation/ Position maintenance / Motion limitation
Description of orthotic:

Instructions, if any:

Signature:

Fig. 3.1 Exemplary model for orthotic prescription.

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 Rational Prescription of Foot and Ankle Orthotics 55

Points to be checked once orthosis/footwear modifications are done are listed in

Box 3.2.

Box 3.2 Postorthosis checks

Comfort of patient
Pressure areas
Gait with orthotics
X-ray with orthotics

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