Pearls On Getting Orthotic Prescriptions Right For Patients
Guest Clinical Editor: David Levine, DPM, CPed
Our expert panelists discuss the importance of biomechanics in their practices and expound on how to properly apply biomechanic principles with orthotics as well as how to remake devices when patients complain that the orthoses are not right for them.
Q: How has the way that you apply biomechanics in your practice changed over the last 10 years?
David Levine, DPM, CPed, cites several reasons for changes in applying biomechanics in his practice. “Having my own orthotic lab puts me in closer touch with the entire process from casting to dispensing to how the patient is functioning,” he explains.
Dr. Levine notes that not all of the biomechanical theories DPMs learn in school have practical day-to-day applications.
“Obtaining knowledge from as many sources as possible including Root biomechanics, pedorthic philosophies and even other specialties such as physical therapy and from orthotists has taught me that an open mind is very important,” asserts Dr. Levine. “We do not know it all and need to continue to learn.”
Over the years, Adam Spector, DPM, notes that incorporating biomechanics into his podiatry practice has taken on greater importance. He says nearly every evaluation of musculoskeletal-related pain in his practice involves at least a brief gait examination and he uses a treadmill to evaluate runners as well.
Gene Mirkin, DPM, notes that early in his career, he did what he learned to do in residency, and was more focused on surgery. However, he came to the realization that not every patient was a surgical candidate and that biomechanical solutions can sometimes resolve the issue at hand.
“ … Many of the problems we see on a regular basis really do respond to mechanical alterations,” maintains Dr. Mirkin. For him, biomechanical control, through the use of strappings and orthotics, has become a precursor to surgical intervention. When patients fail to respond to this approach, he suggests surgery as a possible next option.
Furthermore, Dr. Levine emphasizes that listening to patients and their complaints is critical. He notes that with so many avenues available for patients to utilize self-treatment, they are presenting to practices with more technical information about what works, what does not work and what they have already tried. This has forced Dr. Levine to rethink and change how he applies biomechanics in his practice.
“With the cross pollination and overlap of other medical professionals such as physician assistants, nurse practitioners, physical therapists, orthopedic surgeons and even generalists into the foot and ankle realm, our knowledge of biomechanics and its relationship to foot and ankle pathology is what sets us apart,” says Dr. Spector. “The successful resolution of injuries as well as positive surgical outcomes can only be consistently achieved by taking into account lower extremity biomechanics.”
Q: What changes have you made in prescribing orthotic devices over the last 10 years?
Technological advances have allowed Dr. Mirkin to get away from plaster casting techniques that he calls “tedious, time-consuming and messy.” He first changed to two-dimensional scanning with weightbearing. Although this saved time, he says the inability to capture the subtle deficiencies in the technology, so obvious in plaster molds, was overshadowed by the “wow factor” of scanning and the time he saved using this new system.
When he finally upgraded to the non-weightbearing, three-dimensional scanning technology, Dr. Mirkin acknowledges the mediocrity of the weightbearing scanners became obvious. After the learning curve of using this system, he cites a significant reduction in the number of devices returned for adjustment with this new technology. Dr. Mirkin says his accommodative modifications were much more accurate.
“I couldn’t go back to plaster now and the benefit of the weightbearing scanners is just not accurate enough to go back to that technology either,” says Dr. Mirkin.
In the last decade, Dr. Levine notes that orthotic materials have moved from Rohadur to polypropylene to a variety of materials made from different casting techniques. He has learned there is more than one right way to provide biomechanical solutions for patients, saying that different devices can function similarly. He emphasizes that one should listen to patients and make sure they know that dispensing a device does not mean they are now on their own. Indeed, Dr. Levine says devices sometimes need management depending upon the patient’s activity level, shoe selection and symptoms.
Dr. Spector, who still uses “old school’” plaster casting methods to ensure the most accurate impression of the foot, relates that his modified, basic semi-rigid sports type orthotic has sufficed for the majority of his patients over the years. His specific prescription varies greatly, however, to accommodate for the patient’s diagnosis and individual characteristics and preferences. He listens more carefully to his patients’ needs and shoe specifications to ensure optimal performance and shoe fit.
Q: What do you do when patients complain that their orthotic devices are too rigid?
Dr. Spector explains to patients that prescription orthotics are corrective braces designed to maintain long-term correction and prevent recurrence of symptoms once the acute pain has resolved. Usually, if the orthotics are not comfortable, he explains that the acute pain has not adequately resolved and needs additional treatment such as physical therapy, injections or nonsteroidal anti-inflammatory drugs before the orthoses will work. Dr. Spector will modify rigid orthotics or substitute more accommodative devices only after he is confident that the acute pain is under control.
As Dr. Levine notes, the most important thing is to listen to the patient and then figure out why the device is too rigid. Is it a foot with a restricted range of motion that needs more shock absorption? Is it related to shoe selection? He says focusing on only one type of device without analyzing the patient’s needs can lead to a complaint of a rigid device. Dr. Levine likens this to performing an Austin on every bunion — some will fail but some will do great. He stresses the importance of picking the right material for each patient and adds that having his own lab enables him to work with patients more liberally if a remake is necessary.
If patients have followed all of Dr. Mirkin’s break-in instructions and still complain that the devices are too rigid, he remakes the orthoses as more flexible devices at his own cost.
Q: Do you ever have to remake orthotic devices due to patient complaints? If so, why do you think that happens?
If one makes enough orthoses, Dr. Levine says there will inevitably be complications as it is impossible to make the perfect orthotic for everyone. He notes the key is addressing complications before they happen. Dr. Levine suggests explaining to the patient that orthotic devices should be like glasses. You can go to the drugstore, buy reading glasses and definitely see better but he says if you want the best possible vision corrected for each eye, you need a prescription. Dr. Levine says the same is true for OTC orthoses. They should be very comfortable for both feet, according to Dr. Levine.
First, Dr. Mirkin applies strapping to all his patients. If patients benefit from the short-term control offered by a low-Dye strapping, he says the odds are “overwhelming” that they will benefit from an orthotic. However, he does acknowledge there are the occasional patients who just don’t like the way their devices feel. Dr. Mirkin always initially tries to modify the orthoses himself. However, if the devices look like they fit well and offer the correct fit and control, and the patient is still not happy, he will remake the orthoses.
Most of the time patients are unhappy with their devices when one chooses the wrong material or due to poor scanning technique, according to Dr. Mirkin. If one does not hold the foot against the glass in subtalar neutral, he says the scan is skewed and one must redo it. At times, Dr. Mirkin says his additions (like a Morton’s extension or metatarsal pad) seem like a great idea but are not so he must make adjustments.
“The usual scapegoat, lab error, has really been taken out of the equation with the new scanners and knowledge of the right labs,” notes Dr. Mirkin.
Prior to remaking devices, Dr. Levine advises podiatrists to ensure that the patient is wearing appropriate footwear that not only accommodates the devices but will enable the foot to function efficiently. He also says ensuring all the basics are covered before remaking orthoses is helpful. In order for the foot to function efficiently, the shoe and the foot need to work together. For example, he suggests holding the shoe in your hands to check where the shoe flexes. Dr. Levine says the flex point of the shoe should be at the ball of the foot so when entering propulsion, resistance will be minimal. If the break point is anywhere else, he notes more energy from the foot to overcome the shoe will be necessary. Then if a remake is needed, Dr. Levine says patients “will have a better understanding of what they should expect, but also have even more confidence in your care when you show them how you stand behind your work and what you produce.”
Dr. Spector rarely has to remake orthotics, citing good quality control and checking orthotic casts before sending them to the lab. He listens carefully to patient preferences initially but sometimes patients will change their mind and shoe preferences so he will try to be creative and flexible to make it all work. Dr. Spector has previously sent the patient’s shoe or previous orthotics to the lab to find the right combination.
“In the end, I try my best to make my patients happy, which may involve a little trial and error with a cooperative lab,” says Dr. Spector.
Dr. Levine is in private practice and is also the director and owner of Physician’s Footwear, an accredited pedorthic facility, in Frederick, Md.
Dr. Mirkin is board certified in foot surgery by the American Board of Podiatric Surgery and board certified in foot and ankle orthopedics by the American Board of Podiatric Medicine. He is a Fellow of the American College of Foot and Ankle Orthopedics, and a Fellow of the American Society of Podiatric Surgeons. Dr. Mirkin is in private practice in Maryland.
Dr. Spector conducts bimonthly multispecialty running clinics. He is board certified by the American Board of Podiatric Surgery and is a Fellow of the American Society of Podiatric Surgeons. He is in private practice in Maryland.