Thoughts from Don | Better Casting for Challenging Feet

I continue to be absorbed by sharing skills with practitioners, especially those involving correction, handholds and casting for patients whose feet don’t correct to a balanced position. I define a typical balanced position on three axes—the heel (straight and vertical), the forefoot (level) and the ankle (with a 3-degree-range of dorsiflexion).

Two efforts are crucial on the part of the clinician in this situation: (1) to cast accurately, and (2) to develop the context so everyone involved in building the DAFO is aware this is not a typically correctible foot.

At Cascade, we produce about 300 DAFOs per day. (Our DAFO casting footplates are ideal for typically correctible feet, but the footplates are not meant to be used for challenging feet.) The many people involved in producing an orthotic are especially attuned to situations where the foot that a cast represents may not be typical, and they are highly skilled at using their best judgment in visualizing the patient’s true foot. (This refers to my “Contextual Training” article in the April Dafo Dynamics.)

Here are some things you can do as the practitioner.

To greatly clarify the patient context, include a photo or two of the foot uncorrected, as well as held in a corrected position. Digital photos are very helpful. Print them out and send them to us with the cast. Write the patient name and area of concern on the printed photos (example: Shelley Washburn. Rocker bottom heel, navicular, first MP joint).

When rehearsing the correction handhold (grip) for the cast, apply corrective force on the hindfoot, forefoot and ankle to the patient’s level of comfort.

When a patient’s foot is not held in correction, the skeleton displaces significantly. We make every effort to “honor” those boney prominences with extra padding for the patient’s greatest comfort under correction. This ensures the best chance of effective orthosis. Please make a point of noting boney prominences when you fill out the DAFO order form. The section to the bottom left shows examples of both helpful and ambiguous notations.

One thing I’ve noticed: to make the feet approach typical or “normal” correction, there is a tendency to make the toe shelves level, but that might not work with patients whose feet don’t correct to a balanced position.

If you experience challenges casting feet that don’t correct to a typical position, consider taking one of our workshops. We sometimes bring in patients to help us demonstrate: they really enjoy helping “teach” their clinicians.

And a last word: when you are rehearsing your grip and carrying out the casting, be light-hearted. If the patient thinks the casting exercise is somewhat playful (rather than a tense ordeal), then you’re on the right track. Your patient (and those feet) will relax much more willingly if everyone is having a little fun.

– Don Buethorn

Don Buethorn, CPO, is founder-owner of Cascade Dafo, Inc., and Cascade Prosthetics and Orthotics.

Before correction Corrected position Good notation on the order. Special instructions with this order: “Heel, forefoot and ankle angles are not fully correctable.” (This corresponds well with the cast correction choices.) Bad notation. Special instructions with the order: “Feet can be corrected to neutral. Right hindfoot is fixed into valgus position.” (This conflicts with the cast correction choices.)