Formthotics Presentation to support a practical seminar presented by Mr John O Regan at Harborne Physiotherapy & Acupuncture Clinic, November 2016.

1. Entering the
Foot Zone:
Training course
John O’Regan

2. Health, Safety & Housekeeping
• Toilets
• Fire Exits and Assembly Points
• Mobile Phones on Silent if not off
• Tea & Coffee

3. Before we begin…
• Reference materials course booklet.
• Shoes off and feet at the ready.
• Open format – I will be offering a
podiatric/physiotherapy approach.

4. Course Objectives & Outcomes
At the end of the session(s), participants will be able to achieve the
following:
• Assess Patients Confidently and Effectively using the 6 TestsTM.
• Identify any Limitations, Abnormalities or Conditions Impacting upon
their Prescription of Foot Orthoses, when using the 6 TestsTM.
• Rationalise and justify the appropriate prescription and clinical
application of foot Orthoses.
• List any contraindications, dangers & precautions.
• Confidently and appropriately issue, adjust and review foot Orthoses for
a patient.

5. Introduction to Orthoses

6. https://www.youtube.com/watch?v=sMwnUyBXbOw

7. Polyethylene vs. EVA Compression
Moulded Foam
Formthotics™ Polyethylene Foam
• High grade proprietary thermoformable polyolefin closed cell
foams made specifically for Formthtoics™
• Foam is firmer, more resistant to heat, and will hold a better
moulded shape longer and more accurately than an EVA.
• Non-porous and flexible, lightweight, supportive,
• Contains Ultra-Fresh™ - anti-microbial agent resistant to
fungi, mould, bacteria
• Made in Christchurch, New Zealand since the 1970s
• Mouldable at relatively low temperatures - 85 degrees
• Re-mouldable any number of times
Page 7Foot Science I Name of Presentation

8. Formthotics™ 3D Milling Process
• Formthotics are 3D milled from a block of
foam – ensures an even density of foam
through out the orthotic
• Not heavily compressed in thin areas – as is
the case with compression moulded
products
Unique Tear Drop Shape
• The base is not flat – the base of
Formthotics is 3D Milled
• Talo-navicular support or triplane wedge that
is built into Formthotics
• Place where can most effectively alter the
axis of the STJ

9. Formthotics
History and Evidence
• Invented by a Sports Medicine
practitioner Dr Charlie Baycroft
and professional skier David Boyd
in the 1970s
• Formthotics have treated millions
of people around the world for
over 35 years
• Manufacturing leader – first
Automated Formthotics Machine
(ATM) developed by Steve Gurney,
circa 1988
• Today an established exporter - in
around 25 countries supported by
an established global community
• Proven. Supported by
independent research. See
www.formthotics.com/medical

10. Significant research about Formthotics
10
Formthotics might be as effective as
prescribed customised foot orthoses
Landorf, K., Keenan, AM & Rushworth, L. (2001).
Foot Orthosis Prescription Habits of Australian and
New Zealand Podiatric Physicians. JAM Podiatry
Med Assoc 91(4): 174-183.
Formthotics optimise plantar pressure distribution
Chia, J., Suresh, S., Kuah, A., Ong, J., Phua, J & Seah,
AL (2009). Comparative trial of the foot pressure
patterns between corrective orthotics, Formthotics, bone
spur pads and flat Insoles in patients with chronic
Plantar Fasciitis. Ann Acad Med Singapore; 38:869-75.
Formthotics treat Plantar
Fasciitis
Landorf, K. & Keenan, M.
(2006). Effectiveness of Foot
Orthoses to Treat Plantar
Fasciitis: A Randomized Trial.
Arch Intern Med; 166:1305-
1310.
Formthotics decrease back pain and lower limb
injury
Larsen, K., Weidich, F., and Leboeuf-Yde, C. (2002).
Can custom-made biomechanic shoe orthoses prevent
problems in the back and lower extremities? A
randomized, controlled intervention trial of 146 military
conscripts. Journal of Manipulative and Physiological
Therapeutics.25:5.p. 326-330.
Formthotics are effective in
neuro-motor rehabilitation
Kiruma Hiruma (Teikyo-University),
Kayo Babano (Osaka International
University). Effects of in-shoe
thermoformed orthotic devices on
static and dynamic balance.

11. 6 Tests references
The Unilateral Forefoot Balance Test: Reliability and validity for measuring balance in
late midlife women
Margaret S Clark, PhD, BAppSc(Physio) Research Fellow, Office for Gender and
Health, Dept Psychiatry, Faculty of Medicine, University of Melbourne.
Using the Star Excursion Balance Test to Assess Dynamic Postural-Control Deficits and
Outcomes in Lower Extremity Injury: A Literature and Systematic Review
Phillip A. Gribble, PhD., ATC,* Jay Hertel, PhD., ATC., FNATA., FACSM,† and Phil
Plisky, DSc., PT., OCS., ATC‡
Normative Values for the Unipedal Stance Test with Eyes Open and Closed
COL Barbara A. Springer, PT, PhD, OCS, SCS¹; COL Raul Marin, MD¹; Tamara Cyhan,
RN, BSN¹; CPT Holly Roberts, MPT, GCS¹; MAJ Norman W. Gill, PT, DSc, OCS,
FAAOMPT¹Research Article
Development of Clinical Rating Criteria for Tests of Lumbopelvic Stability
Margaret A. Perrott,1 Tania Pizzari,2 Mark Opar,3 and Jill Cook4
1Musculoskeletal Research Centre, La Trobe University, Bundoora, VIC 3086, Australia
2 School of Physiotherapy, La Trobe University, Melbourne, VIC 3086, Australia

12. Formthotics™ technology
Variety of
shapes and
foam profiles
What are Formthotics?
Custom Medical Orthotics that can be gently heated to mould to the exact
shape of the foot and shoe in the clinic

13. Thermoformable
Page 13Foot Science I Name of Presentation
Before fitting
After fitting
After 2 weeks

14. Flat Heel vs. Round Heel
• Formthotics rounded edge, deep heel
cup
• Was the specific request of very
experienced clinicians
• Gives a much more accurate result of
fitting to their patients and their
footwear.
• Allows the clinician to determine how
Formthotics sit in the shoe.
• Unique to Formthotics Medical
• Flat heel – may make it easier to fit
some shoes but does not allow for
customization of positioning

15. What is an Orthosis?
Orthosis: (noun): “an orthopedic appliance used to Support, Align, Prevent or
Correct deformities or to Improve the Function of moveable parts of the body”
Dorland’s Medical Dictionary
Orthoses are also referred to as:
 Orthotics
 Orthoses
 AFO’s
 TCI’s
 Arch Supports?
 Insoles?
 Any others?

16. A Foot Orthosis
• Is Not an Insole or Arch Support?
• Custom Made Therapeutic Device?
• Made for an Individual Foot?
• Incorporates the Therapist’s Expertise?
• Improves Foot and Leg Function?
• Effect can be Validated?

17. Efficacy of Foot Orthoses
“Foot Orthoses are effective but their
mechanism of action is uncertain.”
Landorf, Karl B. and Keenan, A. Australian Journal of Podiatric Medicine Volume 32, Number 3, 1998
General Suggestions from various texts include:
• Patient Satisfaction 70 to 90%.
• Good effect on pain, Plantar Fasciitis, Arthritis.
• Alter position and motion of the foot and leg.
• Change pressure patterns.
• Foot Orthoses alter muscle activity & recruitment (Tib. Ant.).
• Soft Foot Orthoses are as effective as hard ones.
• Posts are not always required.
What do you think?

18. Root Theory model
- a pathway for understanding morphology
Root Theory Model (1954 – 1966)
› Basis was to classify normal & abnormal foot
types (osseous alignment).
› “Normal”/ideal foot alignment occurs when:
• Distal 1/3 of leg vertical
• Calcaneus vertical to supporting surface
• Plantar forefoot parallel to plantar rearfoot
• When in NCSP (also occurs during
midstance period)
Variations from this “normal’ foot
alignment (‘intrinsic foot deformities’)
lead to abnormal foot function

19. “Making foot orthoses is more art than
science and it is surprising that this model has
remained unchanged for so long”
Dr Merton Root
Limitations to Root’s Model
› Single axis models
› Criteria for normal foot alignment
› McPoil et al (1988) - Only 17% of subjects had ‘normal’ foot alignment
› Reliability of measurement procedures
› Questionable interrater reliability for measuring deformities
› Lack of controlled trials on the effects of functional foot orthoses

20. Pronation V’s Supination
RigidMobile
StiffFlexible
ThinnerWider
ShorterLonger
HigherFlatter
Locks Mid Tarsal Joint (MTJ)Unlocks Mid-Tarsal Joint (MTJ)

21. Sequence of STJ Movement

22. Other Principles & Paradigms
The mechanisms by which orthoses bring about a change in the symptoms of
patients is still widely unknown so all theories must be considered. Let us have a
brief look at the following:
• The Tissue Stress Model
• Neuromuscular Skeletal
• Supination Resistance
• Windlass Mechanism

23. Position of
STJ axis
Medially
deviated
Normal Laterally
deviated
Net effect Pronation Neutral Supination
If the centre of pressure (generated from GRF) is
located lateral to the STJ Axis the GRF will pronate
the foot.
Tissue Stress Model
› Elastic properties of tissues
› Magnitude and direction of
ground reaction force
› Oblique forces are harmful
› Foot orthoses alter Ground
Reaction Forces
› Reduce force on the injured
tissue
› Direct forces along the axis of
the bones
Center of
pressure
STJ
axis
Ground
Reactive Force

24. Neuromuscular skeletal
› Preferred pattern of movement (centrally
processed and learned but capable of alteration)
› Orthoses provide signal input to alter muscle
function ideally to allow lower limb to follow it’s
assumed preferred movement activity
› Orthoses that support this path promote a more
efficient locomotive pattern
A paradigm shift: The role of impact
forces and foot pronation
Nigg 2001. Clin J Sports Med 11:2-9
› Suggests that the effect of orthoses is neuromuscular
and there is an individual preferred path of movement
that should be supported
› Devices which oppose this preferred path are
uncomfortable and increase the loading on lower limb
structures

25. Saggital plane
The windlass mechanism
› The windlass mechanism occurs
when dorsiflexion of 1st MTPJ
tightens the plantar fascia and
supinates the medial arch (identified
in 1954 by Hicks)
› The windlass mechanism should
occur when the swing leg passes the
stance leg.
• Leg externally rotates, heel lifts
and the foot supinates to create a
rigid lever for propulsion
› Problems occur when timing is
incorrect or force requirements are
too high

26. Supination Resistance and the STJ axis
› Position of the axis has a
direct correlation with the
amount of force/effort
required to supinate the foot
during mid-stance
› The more medial the axis the
more pronated the foot
position
› The more lateral the axis the
more supinated the foot
position
Sagittal and transverse view of STJ axis

27. https://www.youtube.com/watch?v=ROd1Acma64o
27

28. Lets Name Them!
28

29. Degenerative Joint Disease
29

30. Heel Pain
30

31. Tendonopathies
31

32. Reading The Foot - Practical
Osseous changes
Skin adaptations
Nail Changes
32

33. Tests
assessing foot &
leg function

34. The 6 TestsTM
Test 1: Subtalar Motion Test
Test 2: Alignment Test
Test 3: Supination Resistance Test
Test 4: Jack’s Test (Windlass)
Test 5: Balance Test
Test 6: Forefoot Stability Test

35. Test 1: Subtalar Motion Test

36. STJ Neutral Position
• All joints have a Neutral Position
• Resting idling or loose packed position
• Maximally Congruent Surfaces
• Minimal Tension
• Able to move easily in either direction
• Dynamically stable position
• Restrictions alter the neutral position

37. Test 2: The Alignment Test

38. Closed Kinetic Chain
Changing the position of the
subtalar joint changes the
alignment of the entire
musculoskeletal system.

39. Test 3: Supination Resistance Test

40. Supination Resistance
• Dr. Kevin Kirby 1984
• Craig Payne. Latrobe University, Melbourne, Australia
• Force required to lift the arch
• Average 138 Newton's
• Manual test is reliable
• Relates to the axis of the Subtalar Joint

41. Grading
0- Very Low Resistance
1 - Low Resistance
2 - Moderate Resistance
3 - High Resistance
4 - Very High Resistance
5 - Impossible to Move

42. Test 4: Jack’s Test

43. Jack’s Test
• Force required to activate the Windlass.
• Hicks 1954. Craig Payne 2004.
• Plantar Fascia winds around the base of the big toe.
• Average 62 Newton’s.
• Increased pressure in Plantar Fascia.
• The test needs to be performed to the point of full
movement, unless no movement at all.

44. https://www.youtube.com/watch?v=jepY8LgZzOE

45. Test 5: Balance Test

46. Test 6: Forefoot Stability Test

47. Bringing it all
together

48. 6 Steps
Step 1 - Formthotics selection and fitting
Step 2 - Patient adjustment period
Step 3 - Rear foot modification
Step 4 - Forefoot modification
Step 5 - In-shoe testing
Step 6 - Follow up and ongoing adjustment

49. Step 1 - Selection and fitting
• 6 Steps to create total contact
foot orthoses
• Formthotics are moulded to the
foot within the shoe
• Total contact orthoses provide
neuromotor and mechanical
facilitation

50. Step 1 - Selection
Considerations:
› Patient pathology
› Patient activity
› Patient footwear
Patient centric
decision making
› Patient compliance
Careful selection and fitting results
in customised patient management:
› Neuromotor facilitation
› Biomechanical support
› Functional stability
› Reduce pain
› Unload damaged tissues to allow healing
› Dynamic guidance through gait
› Neuro muscular
› Proprioceptive
› Improve balance
› Comfort

51. Step 1 - Selection
Select the Formthotics model and size Hard or soft foam?
Single or dual density?

53. Step 1 - Fitting
› Carefully trim at the distal end if required. The
existing shoe liner can be used as reference.
› Fit into the shoe (after removing the shoe liner if
present

54. Step 1 - Fitting
› Formthotics are heated in the shoe
› Formthotics are thermoformed (heat
moulded) to the foot and footwear using
the Formthotics Heating Machine.
› Formthotics and shoes are fitted to the
patient and the patient stands
› Ideal foot position is approximated by
having the anterior knee aligned over the
second toe and knees are slightly bent.
54
Formthotics Heating Machine

55. Fitting and heating practical
Work in pairs and fit Formthotics to your partner.
› Select Formthotics
› Fit Formthotics
› Heat Formthotics
You choose:
› Fit heated or
› Fit at room temperature or
› Both!

56. Step 2 - Patient
adjustment period
Patient adapts to Formthotics
› Build up time and activity
› 3 -7 days
› Formthotics form in accordance with the
individual function and patterns of activity
of the patient
› Enables patient’s body to adapt to the
new position

57. Formthotics modification
Why pimp up Formthotics?!
Why do we customise?
› It’s case specific.
› To apply specific forces to the foot
that will result in an improvement in
pain or dysfunction.
57
Hint: It’s not to match these shoes..

58. Step 3 - Rearfoot modification
Wedges apply a force to the
rearfoot
› Medially or laterally wedged
Medial wedging affects function:
› Decrease supination resistance
› Decrease force for windlass
Lateral wedging affects function:
› Decrease rearfoot supination
› Decrease rearfoot lateral instability
Rearfoot modifications include:
› Medial/lateral rearfoot wedge
› Extended rearfoot wedge
› Heel raise

59. Step 4 - Forefoot modification
Wedges apply a force to the forefoot
Forefoot modifications include:
› Lateral forefoot (valgus) wedge
› Metatarsal dome
› Metatarsal bar
› Medial forefoot wedge
› Kinetic wedge
› Dudley extension
› Cluffy wedge

60. Step 5 - In-shoe testing
Footwear effects foot and limb function
Shoes and Formthotics work together
Orthotic therapy may fail due to poor or
inconsistent footwear
Functional in-shoe tests:
› Alignment test
› Balance tests
› Gait analysis

61. Step 6 - Ongoing adjustment
Formthotics can be readjusted and
remoulded any number of times.
› Check every 3-6 months
› Monitor patient goals
› Measure patient outcomes

62. How to buy…
62
www.pattersonmedical.co.uk
08448 730 035 Or
medical.sales@pattersonmedical.com
Quote Promo Code
MR015
To get free heating machine
worth £144

63. More Information
› Course handouts
› www.formthotics.com/medical
› You Tube – Fitting and product
selection videos available

64. Thank You For
Listening!
John O’Regan