Current Concepts In Orthotic Prescriptions
Prefabricated orthoses can play a valuable role in the podiatric practice. Accordingly, our expert panelists offer insights on the key characteristics of these devices and how they utilize prefabs in the treatment of patients. The panelists also discuss the use of orthotics to prevent and treat common soccer-related injuries.
How valuable are prefabricated orthoses in your clinical practice?
All four panelists emphasize the value of using prefab orthoses. Due to the demands and space issues of her private practice, Cherri Choate, DPM, has one prefab option for dress shoes and two to three prefab options for active shoes. When it comes to active prefabs, she uses a device with a deep heel cup, a wide semi-rigid plate, a medial heel skive and an optional topcover. As she tends to encourage in-office modification of prefabricated devices, Dr. Choate prefers having plate and topcover materials that are easy to work with and easy to fit in the majority of active shoes.
For dress orthoses, Dr. Choate prefers the most streamlined device possible. She prefers to use graphite or graphite composite materials with a very shallow heel cup and a neutral, low bulk topcover.
“For many years, I tried to use polypropylene devices for dress shoes and I was only minimally successful. Once I changed to graphite, the patient’s shoe options increased exponentially and the time of use also increased,” notes Dr. Choate.
Jenny Sanders, DPM, dispenses prefabricated orthotics for dress shoes after fitting her patients with a non-dress shoe custom device. Due to the variability of dress shoe heel heights and volume, she notes that a low profile, thin device can be much more versatile than a single custom device.
“The tradeoff is functional control but how functional can a custom orthotic be in a 2-inch high heel anyway?” she says.
Dr. Sanders will also prescribe a prefabricated orthotic when the patient presents with mild symptoms such as plantar fasciitis or metatarsalgia in the absence of other significant biomechanical issues.1
Many patients of Daisy Sundstrom, DPM, bring in over-the-counter inserts they have tried to use in supportive shoegear for various problems without success. She prescribes prefabs for patients with a relatively normal foot type (no excessive planus, cavus or other deformities), especially those with some degree of ligamentous laxity and for patients who would benefit from mild to moderate correction.
Alona Kashanian, DPM, recommends prefabricated devices to 30 percent of her patients who need biomechanical control and correction of their foot deformity.
What characteristics of a prefab do you find valuable?
Drs. Sundstrom, Kashanian and Sanders cite rigidity as valuable with Dr. Sundstrom emphasizing the importance of the prefab’s material and thickness.
“I have yet to find an OTC arch support that is rigid enough to support the average weight of an individual patient without collapsing,” she says. “I usually tell patients, ‘If you can bend it with your hands, chances are, it won’t support your body weight.’”
As Dr. Sundstrom notes, the disadvantage of the prefab is that quite often the device is not wide enough and the medial longitudinal arch is not high enough.
Dr. Sanders values semi-rigidity, ease of fit into shoes and the ability to further customize if necessary. For example, she considers whether she can grind in a plantar fascial groove or add a topcover. For her prefabs, Dr. Kashanian uses a rigid plastic or graphite shell.