Performance Laboratories

Template Name:

Heel Cup Depth: 12 mm

Shell Width: Bisect 1st

Use: Shock-absorbing sport orthotic

Materials: Semi-flexible polyethylene shell •EVA rearfoot post •Soft density cellular rubber arch fill •Non-slip grip bottom •Vinyl cover

Use: Specific orthotic for golf, tennis, sprinting, aerobics and similar activities

Materials: Same as Flex, plus: •Shockabsorbing medium density combination EVA arch fill / forefoot post reinforcement •Memocell over shell from heel to toe

Use: Multi-purpose sport orthotic

Materials: Semi-flexible polyethylene shell •EVA rearfoot post (polished intrinsic post available) •Protective post plate •Intrinsic forefoot post •Vinyl cover

Substitute Superflex Shell

Use: Specific orthotic for marathon, basketball, football and similar activities

Materials: Same as Flex SL, plus: •Shockabsorbing medium density combination EVA arch fill / forefoot post reinforcement •Memocell over shell from heel to toe

Heel Cup Depth: 12 mm

Shell Width: Bisect 1st

Use: Standard biomechanical control

Materials: Semi-rigid polyethylene shell •High durometer EVA rearfoot post (polished intrinsic post available) •Protective post plate •Intrinsic forefoot post •Vinyl cover

Use: Weights up to and exceeding 215 lbs

Materials: Semi-rigid polypropylene shell •High durometer EVA rearfoot post •Protective post plate •Intrinsic forefoot post •Vinyl cover

Use: Increased biomechanical control

Materials: Rigid, thin fiberglass composite shell •High durometer EVA rearfoot post •Protective post plate •Intrinsic forefoot post •Vinyl cover

Substitute TL 2100*

Inset: Stealth Post*

Use: 3 Levels of Torsional Rigidity

Materials: Thin graphite composite shell •High durometer EVA rearfoot post •Protective post plate •Intrinsic forefoot post •Vinyl cover

Flexible 1 2 3 Rigid

Heel Cup Depth: 14 mm

Shell Width: 1st MPJ

Heel Cup Depth: 10 mm

Shell Width: 1st IS

Heel Cup Depth: 12 mm

Shell Width: Bisect 1st

Heel Cup Depth: 12 mm

Shell Width: Bisect 1st

Use: Choice of biomechanical control with sport, functional and podopediatric applications

Materials: Select polypropylene shell •High durometer EVA rearfoot post •Protective post plate •Intrinsic forefoot post •Vinyl cover

Level Control Shell Guidelines
Make Selection	<100 lbs	100-150 lb	151-200 lb	201-250 lb	>250 lb
2.5mm (3/32“)	Semirigid	Flexible	Very Flexible
3mm (1/8”)	Rigid	Semirigid	Flexible	Very Flexible
4mm (5/32”)	Very Rigid	Rigid	Semirigid	Flexible	Very Flexible
5mm (3/16”)		Very Rigid	Rigid	Semirigid	Flexible
6mm (1/4”)			Very Rigid	Rigid	Semirigid

# Case(s)

12 kits per case

Priority Mail
Courier

Repair Forms

Order Forms

Priority Mail
Courier

*UPCHARGE APPLIES

(Lab not responsible for subsequent pairs that are not identical to previous pairs unless "YES" is selected) Previous work order #

Bill Account Check Enclosed

Bill to credit card:

MC Visa Discover Amex

Card #

Apply CC info to future orders automatically

Name On Card

Expiration Date (Month/Year)

Last Name First Name

Occupation

Age Sex Height Weight [VERY IMPORTANT →]

Size: Width:

Heel Height:

Shoe style:

Fit Orthotic To Enclosed Shoes

Identify shoes with Doctor and Patient Name. Send one shoe only. Shoes are not covered by lab against damage or loss.

Participating in these sports:

1

2

Amount of weekly partisipation

Other activities (Time & Type)

Lab director review patient history and/or biomechanical findings and install accomodations and additions accordingly.

		Left	Right
Arch Height Off Weight Bearing	High Medium Low
Arch Height Weight Bearing	High Medium Low
Subtalar Joint Range of Motion	Increased Normal Decreased
Relaxed Calcaneal Stance Position	Inverted Vertical Everted
Neutral Calcaneal Stance Position	Inverted Vertical Everted

		Left	Right
Foot Flexibility	Flexible Normal Restricted
First Ray Motion	Hypermobile Normal Restricted
First Ray Position	Dorsiflexed Normal Plantarflexed
Hallux Limitus	None Moderate Sever
1st Met Length R: mm L: mm	Short Normal Long

		Left	Right
Ankle dorsiflexion	Increased Normal Decreased
Knee Position	Straight Genu Varum Genu Valgum Genu Recuvatum
Equinus	Absent Present

Gait Pattern:

Straight
Out-Toe
In-Toe

Has patient had orthotics? Yes No

If yes, response was: Good Fair Poor

Delete post (0° Lab Std.)

Intrinsic (3° Varus Lab Std.)

Half Post (3° Varus Lab Std.)

Extrinsic (4° Varus Lab Std.)

Post To Lab Std. Above

Post To Table Below

Intrinsic (Lab Std.)

Extrinsic Post Method:

Corner

Bar (1-5)

Forefoot Post To Sulcus

Include 1st MPJ Cutout

Propulsive Wedge

Post To Cast (Lab Std.)

Post To Table Below

	LEFT FOOT			RIGHT FOOT
	Varus	Vertical	Valgus	Varus	Vertical	Valgus
REARFOOT	°		°	°		°
FOREFOOT	°		°	°		°

*UPCHARGE APPLIES

U-SHAPED PAD Left Right Both Firm	HEEL PAD Left Right Both Firm Medial Cut Out	HEEL SPUR HOLE Left Right Both
MET PAD Left Right Both Distal Placement In Shell Firm "	MET BAR PAD Left Right Both Firm "	DANCER'S PAD Left Right Both Soft
MORTON'S EXTENSION Left Right Both Extend Under Digit Reverse Rigid Extension	NEUROMA PAD Left Interspace Right Interspace	SCAPHOID PAD Left Right Both Firm Cut Out Navicular Mark in Cast