A rather interesting lawsuit is taking place in Canada right now. A podiatry association is suing two of its members, charging them with incompetence and pursuing revocation of their licenses to practice. Those in the know say the doctors allegedly prescribed functional orthoses for 25 patients that either should have been given accommodative orthotics or did not need orthotics at all. Additionally, there is an allegation that the doctors in question were not doing a full biomechanical exam when prescribing orthotics.
This lawsuit raises a number of questions, but perhaps the most intriguing one centers around the notion of the “full biomechanical exam.” There’s an ambiguity about what you should look for in these exams. Not only do the measurements vary from tester to tester, but DPMs seems to place different degrees of emphasis on which measurements carry the most weight. Other podiatrists seem to rely less on particular measurements and more on their clinical experience and subjective gut feelings.
With this in mind, perhaps it’s time to consider and re-emphasize the commonalities between the different approaches and opinions on what constitutes a full biomechanical exam. After talking to a few DPMs who specialize in orthotics, a few key similarities did emerge.
• Get the patient history. There is a universal consensus on this point as DPMs strongly emphasize listening to the patient’s complaints first. Indeed, this is the very first step on the road to finding a specific solution for the patient’s problem or activity.
• Check the shoes. This has been described as “an integral part of the examination.” Not only should you look for abnormal wear patterns, but it also helps to remind patients to wear a variety of shoes.
• Perform both the static and dynamic examinations. Some question the need for, and validity of, static measurements, but others feel it’s important to assess the patient’s range of motion and joint position while he or she is sitting in a chair.
However, there seems to be no debate about the dynamic examination of the patient’s gait, as it is essential for discerning any functional compensations that occur. At the very least, you should observe the patient walking from the front, back and side. A leading authority in this arena emphasizes that “missing the body in motion from multiple views often leads to inadequate treatment and less than acceptable outcomes.”
Depending upon what you find at this point, some strongly advocate doing video gait analysis along with in-shoe pressure analysis. However, others point out that it’s an uphill struggle to get reimbursed for using these modalities.
• Consider other key measurements. Determining the position of the axis of the subtalar joint in transverse plane can help you tell the difference between an over-pronator and an over-supinator. This will enable you to make modifications to orthoses that will resist pronation or vice-versa.
Other orthotic prescription pearls include gauging fat pad width of the heel upon weightbearing (to help safeguard against a confining heel cup) and determining the maximum eversion height (which tells you how far you can evert the forefoot).
Again, this is, by no means, a conclusive list of what constitutes a sound biomechanical examination, but rather an attempt to clarify successful commonalities between different approaches. Certainly, if new technology (such as in-shoe pressure analysis) gains mainstream acceptance, the standards will change. Hopefully, embracing both common successes and new ideas will lead to more consistent and satisfactory outcomes in the very near future.