Pertinent Roundtable Insights On Indications For Orthotic Management

Guest Clinical Editor: Ronald Valmassy, DPM

A: Dr. Burns and Dr. Kirby say cost concerns can be a factor. Dr. Kirby uses prefab orthoses for patients who cannot afford the higher price of custom molded foot orthoses. He adjusts OTC orthoses in the office for these patients until the devices function as much like a custom foot orthosis as possible.
“Interestingly, when I have modified the OTC orthoses of those patients who ‘cannot afford custom foot orthoses’ so their symptoms resolve, many of them are soon able to afford custom foot orthoses so they can have a more long-lasting solution to their foot and lower extremity pain,” points out Dr. Kirby.
When orthotic control is indicated, Dr. Burns says patients frequently ask if there is an alternative to custom functional orthoses. He acknowledges the argument, often made by insurance companies, that one should try OTC supports before custom functional orthoses. For the common complaint of plantar fasciitis, Dr. Burns says it is initially reasonable to combine OTC orthoses with calf and plantar fascia stretching as well as a heel lift if indicated.
In regard to plantar fasciitis, Dr. Burns initially will use low Dye strapping with stretching. If most of the pain resolves, he suggests another week or two of taping along with continued stretching. If the patient does not respond well at first, he uses anti-inflammatory therapy. For persistent symptoms, Dr. Burns encourages patients to use custom functional orthoses. He says such devices are definitive and are an adjunct to continued treatment. Dr. Burns also says prefab devices can be effective for metatarsalgia if patients need cushioning.
Dr. Blake says one can use a prefabricated orthotic initially on all patients with biomechanical issues. He notes that DPMs can learn the right amount of canting if foot stability is a factor and if the patient has any unique sensitivities.
“OTC products are so much less durable in general than custom made plastics so they will never replace them,” explains Dr. Blake. “(Prefabs) can give reliable support for two to six months but then nosedive in stability.”
Dr. Kirby uses OTC orthoses for patients who need immediate pain relief and cannot wait for the fabrication of custom devices. However, as soon as possible, he will schedule patients for orthotic modification to facilitate better fit and reduce the abnormal external and internal forces in the foot and lower extremity that are causing symptoms.

Q: What foot problem do you personally find is the most challenging to treat with a functional foot orthosis and why is it so difficult? What specific orthotic modifications do you utilize to improve your outcome in these cases?

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