How To Overcome Obstacles With Custom Orthoses
“No matter how perfect an orthotic device is, it is only as good as the shoe in which it is placed,” asserts Dr. Levine. “In my opinion, shoes cannot be emphasized enough to our patients.”
When writing orthotic prescriptions, Dr. Levine says DPMs often focus on degrees of varus, valgus and rearfoot post motion. However, he says this is all completely negated if the shoe is inappropriate or excessively worn. Dr. Levine emphasizes that the shoe needs to function with the foot, not against it, and that custom molded orthotic devices must fit the foot as desired. He adds that the orthoses also need to fit the shoes and he says this can sometimes be an issue depending upon the shoes patients select. Once the physician has addressed all of these factors, Dr. Levine says there is a very good chance of achieving the initial treatment goals.
Dr. Fritz cites a patient with a severe hyperpronated foot type. He says the well intended and designed orthotic devices for such a patient may be lost if one places the device in a thin, soled “bobo” style sneaker. He says a straight, wide lasted sneaker (such as the New Balance 1122, Brooks Beast or Brooks Addiction) will provide a wider base of support for the orthotic and the patient’s foot. Dr. Fritz says the shoe last must conform to the patient’s foot, noting that straight lasted and curve lasted shoes can add to the orthotic benefit and to the overall fit.
Patients with diabetes need extra depth shoes with accommodative features, according to Dr. Fritz. He says shoe rigidity, sole materials and counter materials may add to the function of the orthotic in controlling abnormal foot motion. Dr. Fritz encourages clinicians to take the heel height of the shoe into account with the fabrication of the orthotic device, especially when it comes to women’s fashion, in order to allow for proper seating and post elevation.
Dr. Fritz emphasizes communication with patients about problems and expectations.
“The discussion increases orthotic success in any practice. The days of fabricating an orthotic and handing it to the patient to deal with the shoe fit problems are over,” says Dr. Fritz. “The podiatrist who understands the interrelationships between shoes and orthotics will have more successful outcomes. Communication, education and understanding between the podiatrist and the patient are paramount for success.”
A Guide To Using Rigid Materials In Orthoses
Rohadur had been the material of choice many years ago. How often do you use a material that rigid now for your patients? If you do use rigid materials, how do you decide when to use them?
In general, Dr. Levine says rigid devices will be successful in situations in which the patient has a lot of subtalar and midtarsal joint flexibility as rigidity provides more control of the foot. Materials such as Superglass, TL2100 and others provide the rigidity needed, according to Dr. Levine. He notes the contour of the orthotic device also contributes to rigidity. In a foot with a low arch, materials do not function as rigidly as in a high arched foot, explains Dr. Levine.
Depending on the rigidity needed, Dr. Levine says polypropylene is one of many materials that can work well. He adds that different thicknesses of polypropylene indicate different rigidities. Although there are conflicting findings in the literature, Dr. Fritz says many feel rigid materials including polypropylene are superior for control. He uses a rigid component or at least a semi-rigid component in 75 percent of all the orthotics he fabricates in his office. The semi-rigid component often can be a thin polypropylene shell that will help eliminate deformation, according to Dr. Fritz.
Dr. Warkala uses rigid materials like carbon fiber composite materials for about 5 to 10 percent of his patients. He bases the decision to use rigid materials on biomechanical exams as well as the types of shoes in which the orthotics will be worn.