How Current Orthotic Thinking Influences Orthotic Prescription
When it comes to casting, Dr. Fritz’s greatest concern is about the neutral cast he sends to the lab as well as the way the lab applies the plaster additions to the positive mold of the patient’s foot. In particular, he focuses on the negative impression. He says his experiences as a lab technician have taught him that “all cast impressions are not created equal” and he has seen “appalling” foot impressions.
Dr. Fritz still uses a plaster mold of the foot, calling it the most accurate and reproducible casting method. Although casting techniques vary, he prefers the supine position with the STJ in neutral and the midtarsal joint loaded. However, he does note that the profession is taking casting short cuts, namely having assistants take cast impressions and using foam boxes to eliminate clean-up. In addition, Dr. Fritz says computerized casting techniques raise questions regarding reliability and accuracy. He notes that the positioning of a patient’s foot on a digital scanner, mass production and possible lack of quality controls all affect the final positive mold.
A perfect impression takes into account all prominences and individual idiosyncrasies of the foot, notes Dr. Fritz. He will personally take all positive molds and the lab he uses makes an “individualized, truly handmade” custom orthosis.
For Dr. Valmassy, gait evaluation plays a large role in his dispensation of orthoses. During his initial evaluation for consideration of an orthotic device, he will spend a moderate amount of time evaluating the gait of his patient. If the patient has a fairly normal gait pattern, he might be less inclined initially to prescribe a functional foot orthosis or may proceed with other diagnostic or treatment considerations.
As Dr. Valmassy notes, the patient’s gait becomes more consistent and easier to appreciate the more the patient walks. For example, he says patients will typically walk in a fairly awkward fashion initially so he allows them to walk up and down the hallway repeatedly so their normal gait pattern will emerge.
In addition, Dr. Valmassy cites the importance of low-Dye taping, which he will apply at the initial visit when considering functional foot orthoses. He also gives the patient instructions on how to reapply the taping as well as materials so they may duplicate the tape a second or third time if necessary.
If there are minimal levels of improvement from the initial taping and none with the subsequent taping, Dr. Valmassy may have concerns in regard to proceeding with the orthotic device. On the other hand, if there is some success, generally a 50 percent or greater relief of symptoms, he proceeds with the functional foot orthotic device.
As for the device itself, choosing materials will also affect the clinical result, according to Dr. Fritz. He notes the importance of communication with the patient and advocating realistic expectations of style and footwear. Dr. Fritz suggests asking the patient how much he or she is willing to change the footwear in order to fit an orthotic.
Dr. Fritz notes the prescription needs to be realistic for each patient. He notes he will direct his attention to where the patient places the greatest load on the foot. His more involved discussions with the patient result in more requests for a second orthotic. Dr Fritz notes that a provider who spends the time discussing activities and footwear will have better adherence and outcomes. Before completing an orthotic prescription, he always discusses patients’ footwear and at times their willingness to compromise.
Dr. Fritz practices at Allentown Family Foot Care in Allentown, Pa. He is a Fellow of the American College of Foot and Ankle Surgeons.
Dr. Huppin is the Medical Director for ProLab Orthotics/USA and is in private practice in Seattle.
Dr. Valmassy is a Past Professor and Past Chairman of the Department of Podiatric Biomechanics at the California College of Podiatric Medicine. He is a staff podiatrist at the Center for Sports Medicine at St. Francis Memorial Hospital in San Francisco.
Dr. Spencer is an Associate Professor of Orthopedics/Biomechanics at the Ohio College of Podiatric Medicine. He is also a Diplomate of the American Board of Orthopedics and Primary Podiatric Medicine.