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16/10/2024

is built different. It’s hard to articulate what I witnessed and the resilience of the guy. Incredible guy surrounded by an incredible team.

16/08/2024

One thing about making your own orthotics, you pay a lot more attention to the little details in the production process that can make the wear and comfort for the patient better.

A little tidbit I have picked up, let the cover ride up a bit higher and cut it a couple of mm above the shell of the device. It seems to hold up a lot better and patient’s tell me it feels more seemless, not noticing the edge as much.

My theory is that the little bit of movement that it enables holds it up better to the friction and shear forces that might otherwise pull or rip the cover down.

11/06/2024

Seems counterintuitive but a great gold nugget for treating heel pain can be removing the covers from the heel.

Counterintuitive because often a patient with heel pain will express their desire for MORE cushioning but if you are confident that their pathology is plantar fascial related rather than fat pad, calc stress etc than it can work nicely.

If I see a force graph with extended periods of heel contact WHILST the forefoot has begun loading this is a flag for me to consider this. If the heel continues to be in contact with the ground whilst the forefoot is loading, we assume that the medial longitudinal arch is elongating and with it the plantar fascia. Not ideal if you are trying to reduce the stress on the plantar fascia.

IF this is the case, reducing the “comfort” around the heel by reducing the cushioning element, it can shift the rearfoot to forefoot loading quicker. Not dissimilar to how a heel raise might work.

(Red line in graph = rearfoot force, greeny yellow line = forefoot force)

This is a tidbit I have monitored and noticed on force graphs and force overloads for a while after watching Howard Dananberg talking about it but frankly, you don’t need force data to give it a crack and see what happens.

Sometimes the biggest barrier to this is the patient’s feelings around it, especially because the comfort whilst they stand on the orthotic in the clinic might not be A+.

05/06/2024

I am loving being able to see the design of an orthotic through the entire process from the design to the production and fitting process.I am finding that I am getting a much more accurate, seamless level of offloading.

My go-to offloading technique for forefoot pathologies has often been a met dome or bar proximal to the area that I am trying to offload. Functionally, this made more sense to me than making a forefoot pad and doing a cutout.

Interestingly, what I am finding with the 3D printing process is that I am not having to add on these external pads as much.

Perhaps it is because the innersoles are more accommodative in the sense I am able to “bring the ground” up to the areas surrounding the foot more accurately and with more precision. Perhaps it is because it is easier for me to add in internal metatarsal bars to hit the transverse arch with more accuracy and precision? Perhaps it is just the ability to design the forefoot section and not stop at the metatarsal heads.

Either way, I am finding this method much more effective. This patient has a painful recurrent corn on the 2nd met head. The old orthos we made her reduced the peak forefoot pressure from 37.1N/cm to 26.9N/cm. A reduction of 27%. Heaps but ultimately, not enough. With the orthotics without any external padding it reduced it further to 22.1N/cm, another 17% from the old orthos with padding and a reduction of 40% from the shoes alone.

This was great and was satisfied with this but thought I would check with a poron met bar as this would usually be my go to. It did reduce the force by another 1.5N/cm but it also felt a lot more intrusive. Ultimately we decided to go ahead without it, the deflections and 3D printed orthotic worked so well and with an overall 40% reduction in peak force, the trade off of the innersole being more uncomfortable wasn’t worth it.

29/05/2024

One of the most common questions I get from other Podiatrists is how easily does the Zebris treadmill integrate into my consults. I think after a few years practice, most podiatrists get into a rhythm on how they conduct their assessments and most are probably under a time crunch. Any change of habit can be difficult and if there are friction points, it may not be used to its full potential.

For me, Zebris is a fundamental part of the treatment now and integrates seamlessly, primarily because of how easy it is to use. Nowadays, all of my weight bearing assessments and visual assessments are done standing on the platform. From there it’s easy to start a gait assessment and tie in what we have seen and what we have been able to measure.

I think a lot of Pods have been burnt by other assessment tools or gadgets who also promised achievable and accessible data but failed to make the process easy enough to warrant using it every day. It’s probably why I have taken to it so much, because those friction areas of importing patient information, setting up, warming up, calibrating, exporting data just don’t exist.

It makes intervening and reassessment easy and frankly the information you will get from comparing those two assessments saves the conversation time you might have spent otherwise explaining to the patient why you might be putting on this met dome, what you are hoping to do etc etc.

23/02/2024

Patient with mega corn/IPK 5th met head going on a 2 week hike. “Wants to get sorted before leaves in 2 days time” Beautiful, podiatrists dream 🙄

Pressure analysis shows a big fat high pressure area, no surprises.

Enucleated, still sore. Pad and offload, still sore.

3D scan, 3D print innersole, chuck a cover on, come back tomorrow to fit them for your boots. Right the first time, perfectly positioned, instant, comfortable on the first step and the pressure area minimised ✅

How easy.

19/02/2024

3D printing coming to the rescue again.

A really simple solution to an annoying problem. Some structural changes meant this patient’s clawed 2nd digits was pressing in to the ground with a lot of force at toe off each step - see high pressure areas shod and barefoot photos 3 and 4.

The toe itself gets painful but it’s also caused long term damage to the toenail and meant regular appointments to thin it down before it gets too painful.

The solution for us was to try a “toe bar”, anyone familiar with birkenstocks would know what these are, a gentle raise that goes underneath the toe (filling up the space). Feels super subtle and just makes the innersole feel like its “moulded” to the foot.

The effect was immediate. The comparison of pressure shoes how much the peak pressure reduced. A nice easy case of using pressure data pre and post intervention and some 3d printing modifications in action.

08/11/2023

Moving back and practicing in Wagga has been amazing but one area of friction that has been made apparent is the reduced access that we have in regional and rural areas to medical imaging. We are in a fairly large regional setting but we do not have access to bulk billed x-rays or ultrasounds unlike I had previously in Sydney or Wollongong. Patients can get them but they pay good money out of pocket and often have a waiting time.

Without being able to rely on imaging for more accurate diagnosis has meant quite a bit more “trial and error” when it comes to my treatment plans. Often this is fine but sometimes it leads to inefficient treatments and prolonged periods of pain.

This particular case of a 70+ year old with diffuse midfoot pain (pes planus, reduced mobility through joint, end of day pain etc) screamed to me a classic midfoot osteoarthirtis. When it didn’t improve with my classic, go-to regime it had me questioning my skills and thought process.

A simple xray showed the joint itself was fine but there was an accessory ossicle at the area. Small but inflamed and the likely cause of the discomfort. Treatment plan modified by this and no surprises the issue settled.

Whilst only a small inefficiency in my system, it is hard to imagine there are not more widespread inefficiencies that leave people in regional and rural areas disadvantaged to those in the city.

17/01/2023

Reunited with my zebris and gosh it’s good to be back 😁

Really simple one with this patient trying on her new orthotics which we designed to offload the 2nd-4th met heads following a long history of worsening pain through that area of the forefoot🧐

When I eye-balled the orthos I thought perhaps the offloading might not be as aggressive as I would have liked and in the event that I didn’t have pressure mapping I probably would have changed the offloading🦶

Popping the patient on the zebris and on top of the orthotics I could instantly see how low the pressure through the 2nd-4th met head was relative to the 1st and 5th. If anything they may be too aggressive in shifting weight laterally ✅

This gives me the confidence to send the patient off with them straight away and is a good reminder that orthotics dont have to look super aggresive to be effective🤠

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