Inside Insights On Common Orthotic Dilemmas

Ronald Valmassy, DPM

   When treating patients with orthotic therapy, podiatric physicians may face various dilemmas on when to prescribe devices or how to treat patients who have used over-the-counter devices to no avail. These expert panelists discuss the use of orthoses after bunion surgery, “retail” orthoses and the treatment of pediatric patients among other issues.

Q: When would you prescribe functional foot orthoses following bunion surgery?

   A: For most hallux valgus patients, David Levine, DPM, CPed, would recommend orthotic devices. “Even more important than orthotic devices is educating the patient about footwear and what to look for,” he advises. “Once (patients are) in the appropriate footwear, then the function and performance of orthotic devices will make a lot more sense as well as increase the chances of patient adherence.”

   Michael Burns, DPM, considers hallux valgus deformity a symptom of midstance midfoot instability and functional hallux limitus. He always suggests orthotic control following hallux valgus repair unless the midstance instability has improved following a Lapidus fusion or some other ancillary procedure. In practice, he encourages patients with first metatarsophalangeal joint (MPJ) pain to try orthotic control before surgery (unless there is secondary involvement of the second MPJ). Dr. Burns maintains that the symptoms often resolve without surgery.

    “This allows the patient a reasonable option regarding treatment for the deformity and its timing,” says Dr. Burns.

   Since bunion deformities are precipitated, perpetuated, aggravated by or accentuate pathomechanical foot and limb function, Joseph D’Amico, DPM, routinely prescribes foot orthoses prior to surgical intervention. As he notes, correction of the hallux valgus does not correct the underlying forces that have created the hallux valgus nor will it prevent those forces from recurring postoperatively.

   Dr. D’Amico incorporates the orthotic device in the postoperative dressing either as an additional layer secured by elastic compression or by placing the orthotic in the postoperative shoe and securing it with Velcro if necessary. He notes that an established patient will already be accustomed to wearing these devices.

   In contrast, new patients who are anxious to have their deformity repaired should wear the new orthotics long enough to become comfortable and secure in their use prior to surgery. Dr. D’Amico says immediate use of an orthotic postoperatively reduces pathomechanical forces through the operative site, which reduces the likelihood of abnormal stress, improves stability and reduces discomfort.

   If he anticipates significant changes in sagittal or frontal plane alignment of the first MPJ, Dr. D’Amico will adjust the orthotic appropriately. His typical modifications may include first ray cutouts or forefoot post adjustments.

Q: Your patient has just spent several hundred dollars for an “orthotic” he or she has obtained from a retail outlet. When asked your opinion on this, how do you respond?

   A: “What you have purchased is not truly an orthotic device but a custom made insole,” Dr. D’Amico tells patients. “The person or automated machine that fabricated this device is not a physician of the foot and leg, is not trained in lower extremity biomechanics, and has not performed a history and comprehensive physical examination. If it has been suggested that this individual is qualified to assess and treat your condition, he or she is actually practicing medicine without a license.”

   While these patients may find these devices comfortable and helpful, Dr. D’Amico says it is unlikely that the underlying cause of the patient’s concern has been identified or properly addressed. He also tells patients these devices may actually be causing more harm than good.

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