Key Insights On Writing Orthotic Prescriptions

Author(s): 
By Lawrence Huppin, DPM, and Paul Scherer, DPM

   When it comes to an effective prescription for custom foot orthoses, podiatrists must consider the dysfunction of that particular patient’s foot in order to achieve a satisfactory clinical outcome. Addressing the specific needs of the pathology producing the dysfunction as well as the symptoms the patient is experiencing makes the difference between treatment success and failure.

   Dispensing the same prescription orthotic for posterior tibial dysfunction and plantar fasciitis will not produce the same successful outcomes as a colleague who prescribes pathology specific orthoses.

   A systematic approach to constructing the most effective orthoses for a patient’s specific pathology takes only a little more time and effort than making generic orthoses. The following five-step system can help clinicians select the most appropriate components for an orthoses. These steps include embracing the concept of pathology specific orthoses and then prescribing correct material flexibility, positive cast modifications, posting, intrinsic accommodations and special additions.

Step One: Understanding The Benefits Of Custom Orthotics

   Stop thinking in terms of generic custom orthoses and embrace the concept of pathology specific orthoses. Selecting custom orthoses with disregard for the particular pathology or foot type of the patient is as effective as selecting an antibiotic without regard to the pathogen or the physiologic condition of the patient.

   A review of the literature has shown that altering the position of the foot may contribute to improved function of some feet. Published research has described how an orthotic designed to invert the calcaneus can significantly reduce the pressure on the posterior tibial nerve in tarsal tunnel syndrome.1 In comparison to performing a varus correction on the rearfoot, placing a greater valgus correction on the forefoot portion of the orthoses dramatically reduces pull or strain on the plantar fascia.2 A particular design of custom foot orthoses can reduce foot pain by 20 percent and foot disability by 30 percent in patients with rheumatoid arthritis.3 Repositioning the first ray via casting method and certain forefoot extensions can improve the range of hallux dorsiflexion in functional hallux limitus.4

   Knowing about the new concepts and still prescribing the same custom orthoses regardless of pathology does not provide patients with quality care and optimum clinical outcomes. The goal of pathology specific orthotic therapy is understanding what foot dysfunction caused the symptoms and focusing on a device design that works to reverse the dysfunction. Spending a few moments reading this article, attending seminars or conferences that present this information or investigating pathology specific orthoses on the Internet can dramatically improve the orthotic therapy segment of a clinical practice.

Step Two: How To Select Appropriate Orthotic Materials

   Select material and flexibility for the shell of the device that meets the needs of the patient’s foot type and pathology. The two most common materials used in the United States and Canada are polypropylene and graphite composite. The comparative value of these materials is not as important as the concept that each material has several thicknesses or flexibility, and each flexibility is specific to the needs of different foot types and pathology.

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