How To Overcome Obstacles With Custom Orthoses

Guest Clinical Editor: David Levine, DPM, CPed


As David Levine, DPM, CPed, notes, one can use a variety of approaches with patients who have trouble tolerating orthotic devices. Although such challenging situations do not arise very often, he says not every patient will tolerate orthoses and one should have a protocol to follow when this does occur. The podiatrist’s objective findings and clinical expertise must be in harmony with the patient’s subjective orthotic wearing experience.    “Matching objective and subjective situations is sometimes very challenging,” notes Dr. Levine.    Orthoses sometimes do not function as well as the doctor intended. Dr. Levine says one can attribute this to the casting technique or orthotic materials. For example, when it comes to a patient with a very flexible midtarsal joint in the sagittal plane, Dr. Levine notes a typical suspension casting technique may not work as well as when one casts someone prone in this position. However, regardless of the casting technique and material selection, Dr. Levine says making adjustments to the orthoses is sometimes necessary. Typically, he notes that if two adjustments do not provide a satisfactory result, it is necessary to remake the orthosis.    Robert Warkala, DPM, tries to be as specific as possible when matching appropriate clinical symptoms to the orthotic’s materials and style. When it comes to patients who cannot tolerate the devices after multiple adjustments, he reduces the amount of correction in the body of the orthotic.    Ray Fritz, DPM, CPed, says it is “a very rare event” for his patients not to tolerate his devices. He praises the orthotic lab he uses and says returns to the lab are rare. Dr. Fritz concedes that adjustments are occasionally necessary and he can do minor adjustments in the office if necessary. He says multiple adjustments are “extremely rare.”    “Tough cases require time and thought but are well worth it for a winning outcome,” says Dr. Fritz. If a device totally fails to contribute to a patient’s comfort, Dr. Fritz starts over and chooses different materials, noting that the expense is minimal since it rarely happens in his practice. He believes there is a device that will provide comfort for every patient and notes the challenge of selecting the best materials and fabricating the best device for each patient.    “Patients have individual goals and desires,” says Dr. Fritz. “It is important to understand their expectations before setting the orthotic plan in motion.”    Depending on the shoe styles that patients are willing to accept, Dr. Fritz notes the patients themselves may also pose some obstacles. For example, he says some patients are resistant to change and insist on wearing dress shoes that do not have much room for an orthotic. He adds that thin graphite orthoses are best for dress shoes. In difficult cases, patients who complain that an orthosis is too hard may more easily tolerate softer orthotics made from accommodative materials or at the very least a combination type device, according to Dr. Fritz.    Dr. Warkala says patients who fail orthotic therapy after multiple adjustments get a refund of any money and the orthotics are discarded. Since devices are custom-made, Dr. Levine says one should offer a guarantee to the patient. He says the guarantee should state that the patient will be more comfortable with the orthotic devices than without or he or she will get a refund.    Dr. Fritz has never had to refund a patient’s money. He says there is always an option or orthotic type that the patient will find comfortable. Dr. Fritz finds it “much more rewarding to proceed with a second attempt in spite of the time to achieve the successful outcome. Successful outcomes in difficult cases are always priceless in terms of the reputation of the practice and future referrals.”    


How do you determine when orthotic devices need to be replaced other than in situations where they are obviously worn out or broken?    

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