How To Maximize The Efficacy Of Orthotic Prescriptions

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Q: What is your feeling regarding OTC foot orthotic devices and prescription orthotic devices?
In Dr. Wernick’s opinion, OTC orthoses work well as temporary devices or in cases in which the patient has a minimal degree of pathology. However, he cautions DPMs to ensure that the device’s medial architecture matches the foot’s medial architecture. “(A failed match) is the main reason that these devices do not work,” explains Dr. Wernick.

Both OTC foot orthoses and prescription foot orthoses “serve valuable purposes” in Dr. Kirby’s practice. He notes that OTC orthoses are readily available to the patient and one may easily mold them in the office to improve the patient’s function and comfort.

Prescription orthoses are more durable and deform less quickly than OTC devices, according to Dr. Kirby. Furthermore, Dr. Kirby says prescription orthoses are much better than OTC orthoses when it comes to conforming exactly to the foot and one may modify the prescription devices “in nearly infinite ways” for optimal function and comfort. He points out that most of those who receive prescription foot orthoses in his practice have already failed OTC orthosis therapy and need “the much greater potential therapeutic benefits” of prescription foot orthoses.

Dr. Spencer notes some people may only need nominal orthotic control for foot function and do very well with OTC inserts. Some OTC inserts may be useful for pediatric patients who need some control of foot function and he says they will outgrow a prescribed foot orthotic device quickly. The efficacy of an OTC orthosis depends on the device itself, according to Dr. Spencer, who says they are not all created equal. Since cost is a factor with orthoses, Dr. Spencer feels one must offer patients a cost-effective alternative and he feels a well-made OTC orthotic can meet that need.

Here is a medial heel skive. Dr. Kirby has used this device to facilitate more effective treatment of symptoms and pathologies caused by excessive subtalar joint pronation moments. (Photo courtesy of Paul R. Scherer, DPM)
Guest Clinical Editor: Scott Spencer, DPM

     In this month’s discussion, our expert panelists discuss the importance of an arthrometric exam, whether one should lean more toward accommodation or control with orthotic prescriptions, and share a few key pearls they have learned over the years in optimizing the effectiveness of prescription orthoses.

     Q: Do you feel that the arthrometric examination plays a relevant role in your orthosis prescribing?

     A: For Kevin Kirby, DPM, the arthrometric examination along with the physical exam and gait exam enable podiatrists to best ascertain the biomechanical etiology of the patient’s symptoms or gait pathology. Whenever Dr. Kirby performs an arthrometric examination, he records the following information for each patient: hip range of motion (ROM), frontal and sagittal plane knee position, malleolar torsion, ankle joint dorsiflexion, hallux dorsiflexion, plantar fascial bowstringing, subtalar joint range of motion, forefoot to rearfoot relationship, first ray range of motion and subtalar joint axis spatial location.

      “Even though many times I find there are only a few abnormalities in the patient’s arthrometric examination, if I had not performed this examination, I would have much less objective information available for prescribing the optimal foot orthosis for my patient,” maintains Dr. Kirby.

     Scott Spencer, DPM, says combining a gait exam with an arthrometric exam provides an appropriate frame of reference for prescribing an orthotic device that can achieve a change in function for the patient.

     Justin Wernick, DPM, concurs about the importance of an arthrometric exam, citing its importance in determining the pathomechanics of the complaint and formulating a treatment. He does not believe most DPMs take reliable quantitative measurements. Dr. Wernick quantifies his assessment with a three-motion scale. Using this scale, Dr. Wernick is able to determine whether the joint ROM is flexible, average or restricted. He says this is beneficial in diagnosing the complaint and formulating an appropriate treatment.

     Q: Some sentiment has been expressed of late that foot orthoses are over-prescribed. Do you think this is true?

     A: From Dr. Spencer’s perspective, he does not think orthoses are over-prescribed. He says patients who get prescribed orthoses need them.

     Similarly, when podiatrists who have a good education in biomechanics and orthotic therapy prescribe foot orthoses, they “have a great likelihood of improving a patient’s function and comfort with a minimum of potential side effects,” according to Dr. Kirby. When a podiatrist with such education and technical skills takes advantage of the full potential of prescription foot orthosis therapy, Dr. Kirby says foot orthoses “are probably under-prescribed since nearly all of their patients could benefit from prescription foot orthosis therapy.”

     In contrast, Dr. Kirby notes that when DPMs without such education use orthoses, the devices do not have “near the potential” to encourage favorable outcomes for patients. Orthoses are over-prescribed in that instance as he notes such DPMs “will make many useless and uncomfortable orthoses for their patients.” Dr. Kirby says probably less than 25 percent of practicing DPMs have adequate training and experience in biomechanics and foot orthosis therapy to realize the full therapeutic potential of foot orthoses due to more of an emphasis on surgery in podiatric colleges, residency programs and podiatric seminars.

     Dr. Spencer notes other healthcare professionals and general businesses that “prescribe” foot orthotics. “I am sure many of these people do a fine job,” he says. “However, I am sometimes leery of these other ‘prescribers’ due to a lack of knowledge on my part of the training they have and the ideas behind the actual device itself.”

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