Clinical Biomechanics Boot Camps

Taking it to the next level!

Global Podiatry and lower limb related courses and seminars

Archives for Foot Orthotics

Lateral Column Support…

…or cuboid notch or cuboid pad or cuboid raise or cuboid elevation or Denton modification or Feehery modification or … it comes by many names. As well as having many names it is used for many reasons. There are lots of reasons and explanations given for what the purpose of it is and I not totally sure on any of them.

Some use it for cuboid syndrome, some use it to stop the foot sliding off the orthotic laterally, some use it to facilitate the movement of the center of pressure towards a high gear propulsion, some use it for … etc

The reason I raise this now is that it has recently been pointed out to me that things like a cuboid notch may not be placed in the right place. It got me thinking.

The cuboid does not “drop” and need to be supported in the sagittal place which is theoretically what a cuboid notch or pad does. Because the cuboid is part of the calcaneocuboid joint, as it “drops” it also everts (rotates). This could be interpreted as that if a cuboid notch or pad is indicated, then not only should it lift up the cuboid, it probably should also try to invert it. This means that our cuboid notch’s need to be moved more medially (but still on the lateral side of the foot orthotic shell), so they can try to invert the cuboid bone as well.

I know my anecdotal clinical experience has been I have had some awesome results and equally have had some absolute disasters where the cuboid notch has made the pain worse, so its mixed. I certainly do use adhesive felt padding on the foot as a treatment direction test to see if the design feature is indicated on a foot orthotic.

I now wonder if my dismal failures with this were becasue when I used the cuboid notch to lift up the cuboid, I was increasing the eversion force on the bone when I need to lift it up and increase the inversion force on the bone. All my cuboid pads are not being moved a little medially now, so lets wee what happens.

The Supination Resistance Test

In the early days of the Clinical Biomechanics Boot Camps we spent a lot of time on the supination resistance test and the concept of supination resistance, as the concept was so new to so many, but as time went by less time was spent on it as the test has become so widely used and quite pervasive when it comes to prescribing foot orthotics.

The test was first described by Kevin Kirby, DPM and we have done a lot of work on it with a number of studies exploring the concept. Along with that research I used clinically and we did a lot of practical sessions on it in the boot camps – all of this lead to what I think was a good understanding of it and just how useful it was to use clinically when it came to the prescribing of foot orthotics in clinical practice. I think those who did the clinical biomechanics boot camps did get to agree with me just how important that the concept was for the prescribing of foot orthotics and understanding pathology. There are a lot of threads on Podiatry Arena on the topic that get updated regularly.

The supination resistance test is simply a test to estimate just how much force is needed to supinate the foot and then applying that knowledge to how much force is needed to come from the foot orthotic. If the force to supinate the foot is high, then the force needed from a foot orthotic needs to be high. No point using a soft flexible foot orthotic in those with a high supination resistance as the orthotic is probably going to do nothing. If the supination force is low, then a soft flexible foot orthotic is going to be adequate. Using a rigid inverted type of foot orthotic in a foot with low supination resistance is probably going to sprain the ankle.

For our research we used a device that we built to quantify it but that device really has no practical use in clinical practice, so the use of the hands and manually estimating is adequate. There are some devices on the market, such as the Keystone that can be used to put a number on it.

What I used to like saying to people who were unfamiliar with the test is to just do it. Get a feel for it. Find those feet that are high or low and see how that might relate to the pathology that the patient has. Get a feel for how people with different levels of supination resistance respond to different foot orthotic designs. You soon start to see patterns.

Are foot orthotics active or passive physical therapies?

Within physiotherapy there has been a big trend to distinguish between active and passive treatments with the general considerations that active treatments are better and the evidence does generally link better outcomes coming from the active treatments. Passive treatments are generally those that are done to the patient such as manipulations, massage, TENS and dry needling. Active treatments are those that the patients does to themselves such as exercises.

Given this division within physiotherapy, the question comes up as to if foot orthotics come under the active or passive category. I assume the answer to this could be based on someone’s preconceived biases as they want them to be a passive treatments when active treatments are seen as better. I do not think foot orthotics come under either category. Arguments could be made either way. There are other types of treatments that do not fit into one or the other category either, so why would you want to try and put them into one or the other? Is there any point trying? If you need foot orthotics, you need foot orthotics. If you don’t need them, then you do not need them. Does it matter if they are considered active or passive treatments?

I do agree that active interventions are probably preferable for a whole lot of reasons that I will not get into here. That does not mean that there is anything wrong with passive treatments (but there is a lot wrong with some of them and others do not have a lot or any evidence supporting them). For example, what is wrong with self massage for plantar fasciitis with something like a PediRoller? Passive treatments are probably better options during the acute phase of an injury.

I am a big fan of the Archies Flip Flops

We call them “thongs” in Australia. The Archies footwear come with an arch support built into them. We sell Archies in our clinic in Melbourne and they sell well. Pretty much everyone who tries on a pair buys them They are that comfortable. What is useful about the Archies is that they can be used by those who need or have foot orthotics but want to occasionally wear this style of footwear.

The other great thing about these is that can be modifiable. I sometime get on the tools and make what I call a MOSI Archie modification for those with a more medially located subtalar joint axis. I made this video on the technique.


I also occasionally answer a question online about them!

The MOSI, the Kinetic Wedge, The Cluffy Wedge

I talk a lot during the Clinical Biomechanics Boot Camps about many different design features that get used in foot orthotics such as the MOSI, the Kinetic Wedge and the Cluffy Wedge to name just a few. They are all useful features and have their places depending on what affect you are wanting.

For example, the Cluffy Wedge is deigned to hold the hallux in a slightly dorsiflexed position. This tenses up the windlass mechanism in the foot and brings on that windlass effect earlier. That is only going to be useful if you want to or need to bring it on earlier. If the windlass mechanism is functioning fine, then the Cluffy Wedge is probably not going to make any difference. That does not stop some clinicians using it as a ‘cure all’ and using it in in most orthotic prescriptions. The Cluffy wedge or a similar foot orthotic modification is indicated when it indicated and not indicated when its not indicated.

Arch Support in Footwear When There is Not Room for Arch Supports

So much of the use of foot orthotics is based on compromises. The ideal foot orthotic and the ideal foot orthotic prescription is often modified away from that ideal to take into account the footwear that they are to be used in. This is particularity a problem in things like tight football boots or ballet flats when you need some form of arch support. These types of shoes are not designed for any sort of support or foot orthotic to go into them. They are minimalist by design. Often what I do for these types of patients is use a self adhesive silicon gel arch support which takes up very little room, but does give some support. There is a little bit of trial and error to get the placement in the shoe right for comfort. It is less than ideal, but better than nothing.