Determining The Best Orthotic Fit For Patients

Guest Clinical Editor: Nicholas Romansky, DPM

Are orthotics prescribed too much or are they underutilized when it comes to biomechanical issues in the lower extremity? In addition to emphasizing a tailored treatment approach for each patient, these experts also detail their casting methods and the standards they use to choose orthotic fabrication materials.


Do you think every patient can benefit from orthotics?


None of the panelists believe in making a blanket prescription for orthoses to every patient. Nicholas Romansky, DPM, suggests the over-prescribing of orthotics can lead to a bad rap for podiatry. Kevin Kirby, DPM, concurs.

   “I don’t know of any ethical podiatrist who would recommend foot orthoses, either prefab or custom, to every patient,” says Dr. Kirby.

   Any treatment recommendations should be geared toward either resolving pathologies that are causing pain and disability, or preventing pathologies from occurring or becoming worse in the future, according to Dr. Kirby. David Levine, DPM, CPed, maintains that orthotic devices represent one step in, what is for most people, a gradual treatment process.

   As part of that process, Dr. Levine suggests starting with a shoe assessment in order to make sure the patient is wearing a type of shoegear that is functionally appropriate. He often proceeds to have the patient try an over-the-counter (OTC) device. If that OTC device is not successful enough, Dr. Levine says the next logical step would be custom orthoses. However, he notes there are some patients who will not tolerate OTC devices so one might need to skip prefabs in these situations and go directly to custom orthotic devices.

   “The bottom line is that it is a case by case, situation by situation determination,” notes Dr. Levine.

   Drs. Kirby and Romansky agree that often in order for orthoses to be successful, one must customize the devices to the individual patient.

   Dr. Kirby recommends custom foot orthoses to many of his patients. He notes that well-made foot orthoses are frequently “the most cost-efficient and therapeutically effective treatment options that are available to treat mechanically-based foot and lower extremities pathologies.” Like Dr. Levine, he often recommends that patients first purchase prefabricated orthoses, which he subsequently modifies in his office, either as a primary or temporary treatment measure.

   Dr. Romansky does note that when patients need orthotics, the devices can not only benefit the lower extremity but the back, hips, knees and other areas as well.
“(Orthoses offer a) universal product that we can use for so many things,” says Dr. Romansky.

   Dr. Kirby adds that the medical profession is currently “underutilizing” well-made custom foot orthoses to treat the great many mechanically-based pathologies of the foot and/or lower extremity that occur.


How do you cast for orthotics?


As Dr. Levine notes, casting for orthotic devices depends upon many factors such as the goal of treatment, the type of device one is fabricating, the shoes the patient will wear and the activity level of the patient. Similarly, Dr. Romansky suggests considering the patient’s shoegear, height, weight, occupation and, most importantly, the problem one is treating.

   Although it is common to cast while the patient is supine with the neutral suspension technique, Dr. Levine notes the technique does not work for everyone. He says some patients need to be cast while prone and some need to be cast while they are in a semi-weightbearing position.

   “Weighing all of the variables, doing a thorough biomechanical exam and determining the goal of treatment will help decide the best way for the patient to be casted,” emphasizes Dr. Levine.

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