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In order to enhance one’s ability to prescribe custom orthoses, this author emphasizes a thorough exam, a focused evaluation of the patient’s footwear, accurate impressions and fabrication, and key nuances to maximizing the effectiveness of modifications.
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Continuing Education Course #160 — January 2008 | - I am pleased to introduce the latest article, “Keys To Facilitating Optimal Orthotic Success,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of complimentary 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.
When prescribing custom orthoses, a variety of factors can optimize the efficacy of the devices. David Levine, DPM, CPed, emphasizes the importance of the patient history and proper footwear assessment in order to ensure an effective orthotic prescription. He also discusses keys to making orthotic modifications and how DPMs can address mechanics via the heel post.
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. 78 and successfully answering the questions on pg. 82. 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. Levine has disclosed that he has no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of his presentation.
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 2008
EXPIRATION DATE: January 31, 2009
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• discuss keys to proper footwear evaluation and how this evaluation impacts a prescription of orthoses;
• review the information one should obtain from the patient prior to taking impressions for orthoses;
• describe the impact of first ray function on orthotic modifications; and
• discuss the role of the heel post and how it can affect one’s biomechanics.
Sponsored by the North American Center for Continuing Medical Education.
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Within the last few years, our attention to footwear has started to come into better focus. While much of the podiatric focus is on footwear for people with diabetes, we treat a much larger population of people with pathomechanical ills. When we have a greater understanding of footwear, our orthotic devices will be more effective.
All of our patients benefit from being treated like athletes. After all, our job is to get people back on their feet, back to work or back to their primary avocation as quickly and safely as possible without pain or disability. In order for this to happen, we need to implement the treatment we prescribe in an efficient manner.
This all begins with the podiatric history and physical examination. Hearing the subjective complaints and concerns of the patient will help facilitate more focused questions and examination. The examination technique should utilize all pertinent information possible that the patient will give and should also follow a consistent pattern from patient to patient. Examining the patient in a static position, sitting and standing, as well as dynamically will help one obtain as much information as possible.
Analyzing gait is also a critical examination tool. It will provide important information that one would not otherwise have in a static examination alone. One can do this simply by having the patient walk up and down the hallway or by utilizing a treadmill or platform walkway.
Insights On Evaluating The Patient’s Shoes
Along with examination of the patient, a history and physical examination of his or her footwear is important as well. Assessing what shoes the patient wears into your office as well as questioning him or her on other types of shoes the patient typically wears is helpful in formulating a treatment plan.
|  | | Before proceeding with the impression process, you need to ascertain what type of shoe the orthotic devices will be worn in and the type of activity in which the patient is involved when wearing the orthotic devices. (Photo courtesy of Douglas Richie Jr., DPM) |
In addition, determine what type of footwear the patient wears when placing the highest demand upon his or her feet. Be sure to look at the sole wear patterns and how the upper of the shoe wears. For example, if the upper of the shoe has collapsed laterally but the patient seems to exhibit more than an average amount of pronation, one will need to factor that into the orthotic prescription. We certainly would not want to put a varus post on a foot that collapses over the lateral counter of the shoe. This would only serve to exacerbate the situation for the patient.
All of the information that one obtains will be preparation for providing the appropriate treatment for the patient. From a conservative biomechanical perspective, this is going to happen with a combination of any or all of the following: shoes, shoe modifications and orthotic devices. The key to making it all work as effectively as possible is to integrate the modalities so the patient will slip into them seamlessly and successfully. For those patients who require surgery, one also needs to take into account the added challenge of the normal postoperative or even a complicated postoperative course.
Treatment begins with the shoe, which is the ultimate orthotic device. Finding the right type of shoe for the patient is the necessary first step. Just like constructing a building, one must establish a solid foundation. One can subsequently add additional modalities and the success will build on itself. Adding modalities on top of a weak or poor foundation may work but doing so may only serve to frustrate the DPM with a less than optimal outcome or frustrate the patient.
Taking a little bit of extra time to focus on footwear will pay large dividends in the end. If you do not have the time or interest in doing this, do yourself and your patients a service, and refer them to someone who does. Patients will appreciate you even more for recognizing your limitations and your eagerness to get them to someone who cares about them as much as you do.
Utilizing The Athletic Footwear Grading System Of The AAPSM
The American Academy of Podiatric Sports Medicine (AAPSM) is an excellent resource. The academy has undertaken the worthwhile project of analyzing and comparing athletic footwear. This has been one of the major priorities this year within the academy. The academy has established a grading system, which separates athletic shoes into categories based on a point system. Ten characteristics of a shoe receive a grade and points. These characteristics include flexibility, sagittal and torsional stability, and even fit.
This grading system can help the podiatrist and the consumer determine which type of shoe would be best for a specific foot type and foot problem. The AAPSM is currently in the midst of expanding the grading system from running shoes to all types of athletic shoes, ranging from golf shoes to cycling shoes. This information is readily available on the AAPSM Web site (www.aapsm.org).
|  | | With greater recognition of first ray function, it is imperative that the orthotic device optimally engages the first metatarsophalangeal joint and hallux. If one adds a cutout, reverse Morton’s extension (as shown above), accommodation or any other type of extension prior to dispensing, it will more than likely be in the wrong location. (Photo courtesy of Patrick DeHeer, DPM) |
A Guide To Orthotic Impressions And Fabrication
Once one has established the footwear foundation, the orthotic device becomes the focus of attention. Before obtaining impressions of the patient’s feet, consider the goal of the orthotic device. Once you have completed the biomechanical exam, you need to ascertain what type of shoe the orthotic devices will be worn in and the type of activity in which the patient is involved when wearing the orthotic devices. After documenting all this, one can proceed with the impression process.
Take the impressions semi-weightbearing or non-weightbearing with plaster, foam, wax or computer scanning. When it comes to taking impressions, consistency should produce reliability. However, not everyone tolerates the same type of device and, even more importantly, there is more than one right way to provide what the patient needs. Making the same device for everyone is like doing the same type of osteotomy for every bunion. One needs to tailor the procedure for the particular situation. In addition, the DPM needs to keep an open mind and be prepared to make an adjustment, modify and, even on occasion, redo devices. What you do not want to see is patients returning to you or another doctor with orthotic devices in their hands rather than in their shoes.
After obtaining the impressions, one needs to fabricate the devices. Fabrication will only be as good as the cast even with the most skilled lab. Attention to detail will determine the prescription for fabrication. Many written prescriptions assume the lab knows more than the doctor. There is obviously more to making an orthotic device than taking a cast and this should be what separates podiatry from all other specialists who fabricate orthotic devices. The prescription will reflect all of the information that one has obtained as well as the goals one hopes to accomplish in the treatment of the patient.
Depending upon the patient, the prescription for orthotic fabrication may need to focus on the hindfoot, the forefoot or both. There are a variety of modifications that one can incorporate into an orthotic device either at the initial time of fabrication, at the time of dispensing or even at a follow-up visit that will be beneficial. The device does not necessarily have to be in its final stage at the time of initial dispensing. It can be a work in progress until you have achieved what you feel you need to.
Pertinent Pearls On Orthotic Accommodation And Modification
For example, perhaps you are attempting to accommodate a painful keratotic lesion or a specific metatarsal head, but it is very difficult to get the exact location based on a non-weightbearing impression of the foot. Sometimes it is better to have the orthotic device partially completed when the patient comes in for dispensing. At the visit, dispense the orthotic devices, mark the area to be accommodated with a marker and transfer it to the partially finished orthotic device that has the forefoot extension attached but without the top cover. The podiatrist can then add the accommodation and the top cover once he or she has successfully marked the location which one needs to accommodate.
|  | | The author says it is very difficult to address a leg length discrepancy with an orthotic device unless the difference is less than 1/4 inch. |
By utilizing this approach, you are completely certain that you have added an accurate accommodative pad. You also have the shoe in your possession so you can optimize the fit of the orthotic devices. When the shoe, the orthotic device and the foot work together, there is a much greater chance of success and a very comfortable result for the patient.
The physician can employ the same approach for the first metatarsal as well. With greater recognition of first ray function, it is imperative that the orthotic device optimally engages the first metatarsophalangeal joint and hallux. If one adds the cutout, reverse Morton’s extension, accommodation or any other type of extension prior to dispensing, it will more than likely be in the wrong location.
This is because the forefoot in a non-weightbearing position will not be in the same location on the device as when it is in a weightbearing position. This is especially true of those feet with a lot of midtarsal joint sagittal plane flexibility. These feet will elongate significantly when weightbearing. There is no doubt that it is time consuming to add the appropriate modification when the patient comes in but it is often the only way to be sure that you have placed the modification correctly. With the foot on the device, you can be sure that all forefoot accommodations are accurately placed.
Hindfoot orthotic modifications are easier to accomplish on the positive models of the foot. Write for these on the prescription. The goal of these modifications is to control the foot at the time of heel contact as the foot approaches midstance. The Kirby skive is an excellent modification that addresses excessive pronation of the foot. Bear in mind that any modification you add does not necessarily have to be on both feet. Many times the biomechanical examination will yield subtle asymmetric findings that require tailoring each device for each foot in a different fashion.
What About Heel Posts?
The heel post is another area where one can address the mechanics. The job of the heel post is to control the hindfoot motion at heel strike. Building in a certain amount of motion within the heel post theoretically allows the foot to pronate a certain amount as it approaches midstance. However, in order for this to work as intended, the heel of the shoe is important to assess. If the shoe is well worn posterolaterally, the motion built into the heel post will have little or no effect. Keeping the heel of the shoe in good repair is critical to a well functioning orthotic device.
There are some situations in which a heel post is not necessary. This would be true for a cycling shoe since there is no heel contact. The forces are primarily within the forefoot. Wedging and posting of the forefoot are necessary but hindfoot control is not. Without the heel post, the orthotic will fit the cycling shoe even better anyway. The same is true for skaters as well whether they are speed skaters, figure skaters or skating for hockey.
A Few Thoughts About Addressing Limb Length Discrepancy
In many patients, one will need to address a leg length discrepancy (LLD). Numerous articles have been written on this subject. It is very difficult to address the LLD with an orthotic device unless the difference is less than 1/4 inch. When it comes to LLDs greater than 1/4 inch, it is better to address this separately from the orthotic device so you do not alter the function of the foot as well as the device. In these cases, use the shoe to your advantage. Skilled hands can do much to address LLDs in a cosmetically appealing and functionally efficient way.
In Conclusion
After dispensing the orthotic devices and completing the appropriate adjustments and modifications, one may have successfully reached the goal in treating the patient. Follow-up visits will help determine this for sure. If the patient needs more help, the shoe may then provide another avenue by which to help improve the outcome. There are many available shoe modifications that will improve function and provide comfort. Some modifications are as simple as alternative lacing techniques and other modifications are as creative as adding a flare or external lateral or medial counter. Whatever it is you might consider, do not be afraid of the shoe or even asking someone who has expertise for ideas on what you can do in a particular situation.
With dramatic advances in our profession’s surgical expertise and more procedures available to help our patients, the role of conservative biomechanical care has become even more important. Indeed, the ultimate goal is to make patients feel and function better.
Dr. Levine is in private practice and is also the director and owner of Physician’s Footwear, an accredited pedorthic facility, in Frederick, Md.
For further reading, see “Keys On Writing Orthotic Prescriptions” in the January 2006 issue of Podiatry Today or “A Closer Look At Orthotic Technologies And Modifications” in the October 2005 issue. Also check out the archives at www.podiatrytoday.com.
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