Inside Insights On The Evolution Of Orthotic Therapy

Guest Clinical Editor: Douglas Richie Jr., DPM

   Over the last decade, there have been a variety of changes and trends that have shaped the evolution of orthotic therapy. Accordingly, our expert panelists discuss pertinent orthotic prescription trends. They also examine the importance of having a strong background in biomechanics and whether the podiatric profession is “giving away” its biomechanics expertise to non-podiatric physicians.    Q: What specific changes have you observed in the overall utilization of functional foot orthoses in the typical podiatric practice in the past 10 years? Are orthoses still an important part of the treatment armamentarium of the typical podiatric physician?    A: During the past decade, Chris Smith, DPM, says the number of orthotics used by podiatrists has “expanded dramatically,” judging by the increased volume of foot orthotics manufactured and the number of new orthotic labs. He notes the use of orthoses is experiencing a “strong upward trend” after appearing to plateau for two or three years.    Both Paul Scherer, DPM, and Douglas Richie Jr., DPM, note growth in the use of custom foot orthoses (CFOs) in the last 10 years. Dr. Scherer attributes the more frequent usage of CFOs to more literature demonstrating the devices’ efficacy. He notes that DPMs who utilize good casting methods and prescription writing have improved results and have accordingly elevated their reputation among other podiatrists.    Dr. Richie ascribes the growth in custom orthoses to the fact that non-DPMs, such as orthotists, pedorthists and physical therapists, are using the devices in increasing numbers. He believes younger DPMs are not prescribing custom devices as often as those who have been in practice more than 10 years. Additionally, Dr. Scherer has seen a change in DPMs prescribing more pathology-specific CFOs. As he explains, fewer podiatrists are prescribing orthoses solely according to a patient’s age or sports activity and more are basing prescriptions on the patients’ specific needs or the pathology that is causing the dysfunction.    Q: What changes or new trends have you seen in terms of orthotic materials that are used in prescriptions?    A: As Dr. Scherer sees it, today’s orthotic trends do not involve manufacturing materials. He notes that polypropylene and graphite composite comprise 98 percent of the custom orthotics that are made. However, he sees increased utilization of cast correction methods including the medial skive, inverted positive technique and orthotic additions such as reverse Morton’s extensions and distal end metatarsal bars.    Likewise, Dr. Richie has not seen any breakthroughs involving orthotic materials in the last 10 years. He feels that polypropylene and composite materials have been used consistently. When he first entered practice, the only type of orthotic was basically a Rhoadur shell with an acrylic post, top cover or extension. These days, he notes most orthotic prescriptions include some type of top cover and full-length extension. New trends include “dress style” orthotics and custom sandal orthotics, according to Dr. Richie.    Dr. Smith says the profession is slowly beginning to use more pathology-specific devices like the Richie Brace and the posterior tibial dysfunction device. He has also seen more use of rearfoot posts and forefoot extensions.    Q: Overall, how has the quality of negative casts or quality of the prescriptions from podiatrists changed over the past 10 years?    A: Dr. Scherer has seen a significant change in negative casts, noting that some podiatrists take impression casts that invert the forefoot on the rearfoot or dorsiflex the first ray. He emphasizes that DPMs who have found success with orthotic therapy employ pathology-specific orthotic prescription writing.    After five years of visiting or lecturing at all the schools of podiatric medicine, Dr. Richie feels some have neglected the art of casting, noting a deterioration in the quality of impression casts submitted to labs. Dr.

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