Jeff et al,


> This is the very type of criticism and cynicism that troubles me.  Let me
> issue a personal challenge to you Simon, and the mailbase, that I
guarantee
> will improve the reliability and repeatability of casting and measurements
> results.  For every cast that you send to a commercial lab for fabrication
> of an orthosis, do each of the following things:
> 1.  Draw the sagittal plane bisection of the calcaneus on the posterior
> aspect of the heel of the negative cast.
> 2.  Using a protractor, measure the degree and direction of any forefoot
> angulation (deformity) relative to your heel bisection and record this in
> the patient's chart (ex. 4 degree everted forefoot).  Compare this to your
> bioeval measurements.  Are they consistent?
> 3.  Instruct the lab to use your heel bisection as a reference for the
> forefoot correction that they incorporate in your casts (orthoses).
> Instruct the lab to measure and record the degree and direction of any
> forefoot deformity they find in your cast.  Have them return this
> information to you along with your completed orthoses.
> 4.  Ask the lab to critique your casts.  They see a ton of them and they
can
> probably give you tips that can improve your casting ability.
>
> 5.  After your orthoses are returned, compare the data.
>
> This is a simple task, nothing too difficult to ask of you or your
> laboratory.  I guarantee that in the next six to twelve months you will
see
> a better correlation of your casting and examination findings and I think
it
> will generate some stimulating discussion.  It will also keep you lab
> accountable and they will certainly pay considerably more attention to
your
> cases than to those who ask nothing of them.
>

Jeff, I currently teach orthotic prescription and manufacture to final year
student's here at the Plymouth School of Podiatry, as such I do not use a
commercial lab. We do however, already use the protocol you outline above,
sometimes. And I agree that measuring forefoot to rearfoot position from the
cast is a good idea, because the measurement of this from the person is
whoeful. However, Mert said we were talking about boney relationships, how
valid is this technique, given the soft tissue thickness on the plantar
surface of the foot? Moreover, I read somewhere recently (I'll try and find
it) that the concept of all metatarsal heads lying on the same plane
(whether perpendicular, inverted or everted to the rearfoot) was just that,
a theoretical concept. The X-rays presented in the paper showed that the met
heads were all over the shop and on independent planes.

Furthermore, in our lab we produce many different types of device; given
that students manufacture some of them, some are good and some are bad and
some are out and out terrible, however, from our audit we still appear to be
making the majority of people better, in terms of pain ( I acknowledge that
this may not be the best indicator). I personally use Root type devices, EVA
accommodative, preforms, simple insoles with sticky wedge, all of which seem
to make the majority of people better. My point and I think the point of the
Meat-pie paradigm is that you do not need to be too accurate to get a
positive outcome- I know because I don't always take measurements and merely
post to what I think will work- and low and behold it does. But by far the
most interesting are the ones wearing the devices under the wrong feet who
still get better- how do you explain this, if accuracy is quintessential to
success?

However, let me set a challenge too ;-)

Lets say I test my between day error in measurements and so I am able to
give your lab the following information for a patient:

Tibial Position: 10 degree tibial varum, 95% C.I. (7, 13)
NCSP: 6 degree inverted, 95% C.I. (3.5, 8.5)
RCSP: 8 degree everted, 95% C.I. (5, 11)
FF to RF: 10 degree valgus, 95% C.I. (5, 15)
Ankle Joint dorsiflexion 8 degrees, 95% C.I. (5.5, 10.5)

What postings does this patient need? ;-)
Best wishes,
Simon




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