Key Insights On Writing Orthotic Prescriptions

Start Page: 67

Continuing Education Course #138 January 2006

I am pleased to introduce the latest article, “Key Insights On Writing Orthotic Prescriptions,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of regular CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.

To prescribe an effective orthotic, one must address patient symptoms as well as the pathology which produced the dysfunction. With this in mind, Lawrence Huppin, DPM, and Paul Scherer, DPM, emphasize the value of custom orthotics and provide a step-by-step guide to selecting appropriate materials and getting the most out of orthotic additions and modifications.

At the end of this article, you’ll find a nine-question exam. Please mark your responses on the enclosed postcard and return it to NACCME. This course will be posted on Podiatry Today’s Web site (www.podiatrytoday.com) roughly one month after the publication date. I hope this CE series contributes to your clinical skills.

Sincerely,

Jeff A. Hall
Executive Editor
Podiatry Today

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 68 and successfully answering the questions on pg. 74. Use the enclosed card provided to submit your answers or log on to www.podiatrytoday.com and respond via fax to (610) 560-0502.
ACCREDITATION: NACCME is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Dr. Huppin has disclosed that he is the Medical Director for ProLab Orthotics/USA. Dr. Scherer has disclosed that he is the CEO and a major stock shareholder in ProLab Orthotics/USA.
GRADING: Answers to the CE exam will be graded by NACCME. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
TARGET AUDIENCE: Podiatrists.
RELEASE DATE: January 2006.
EXPIRATION DATE: January 31, 2007.
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• discuss the general goals of prescribing pathology specific orthotics;
• discuss the differences between vacuum formed and direct milled polypropylene;
• describe the potential impact of orthotic width;
• discuss the rationale for considering or not considering a rearfoot post; and
• discuss the use of the “sweet spot” modification and how it can be beneficial in orthotic treatment of adult-acquired flatfoot or posterior tibial dysfunction.

Sponsored by the North American Center for Continuing Medical Education.

As shown in the above table, the flexibility of a custom foot orthotic is proportionate to the weight of the patient and the thickness of the material. Note the differences in flexibility between vacuum-formed polypropylene and direct milled polypropylene
One can recognize milled polypropylene CFOs by their distinctive milling line. They are slightly less flexible at a given thickness compared to vacuum-formed CFOs.
As one can see here, vacuumed polypropylene CFOs are smooth and shiny in appearance, more flexible at a given thickness and adapt easier to plantar fascia grooves or intrinsic accommodations.
One can prescribe various heel cup depths as a balance between the needs of the pathology and the type of shoe the patient is willing to wear.
The minimum cast fill is the original design (left). Standard cast fill (center) is necessary for some pathologies that will not tolerate the neutral position shape. One would use maximum fill (right) to make the custom orthosis more comfortable albeit le
The Kirby skive or medial skive is a technique that raises the medial side of the heel cup (left cross section) to increase ground reactive force and decelerate pronation by increasing the moment on the medial side of the subtalar joint axis.
The reverse Morton’s extension, usually made of 3 mm cork, is located under the second to the fifth metatarsal head. This allows the first ray to plantarflex and increase the range of dorsiflexion of the hallux.
A metatarsal bar is a cushion of poron that one places on the dorsum of the front edge of the custom orthosis as shown above. It transfers ground reactive force from the metatarsal heads to the shafts.
One would place a sweet spot (see above) at the navicular tuberosity of pathology specific orthoses for posterior tibial dysfunction so the rigid plastic necessary for this device does not irritate this area. This is also an addition of value for plantar
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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.

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