Inside Insights On Common Orthotic Dilemmas

Ronald Valmassy, DPM

   In most cases, he notes such OTC devices were made from a weightbearing foam impression of the patient’s feet. The foam impression allows the foot to deform and spread during the casting process. Accordingly, Dr. D’Amico says it is impossible to reposition or realign the plantar aspect of the foot from this position. In addition, he says with that casting method, one cannot visualize the plantar surface.

   The result is a model of the foot as it is but not as it should be, notes Dr. D’Amico. He tells patients they feel comfortable because the orthotic is distributing the pathological forces over the entire foot rather than one painful segment. Dr. D’Amico says this is similar to buying larger pants to feel more comfortable after gaining weight, which does not address the underlying problem.

   In the same vein, Dr. Levine notes the bottom line is to explain that an arch support is just that and nothing more. A pair of custom devices is more than a step up from OTC devices, he says. Just as prescriptions for glasses differ for each eye, he reminds patients that no two feet are alike, even on one person. Custom devices take even the subtle differences in feet into account whereas the OTC devices are just a pair of the same device, notes Dr. Levine. If the OTC devices do not adequately address the problem or the pathology, he feels it is time to step up to custom devices.

   If the OTC orthoses have a good fit with the shape of the foot and adequately control midstance instability, Dr. Burns tries to work with them. If they do not meet these requirements, he tries to explain the differences to the patient. Dr. Burns notes that sometimes patients have several different pairs and one may be adequate.

   Dr. Burns acknowledges a conundrum when patients have tried several varieties of orthotic control and still have symptoms that may be amenable to orthotic therapy. “Should I assume that their symptoms will not respond to orthotic control and propose another treatment strategy (often surgical), or should I try to convince them to try yet another orthotic device?” he asks.

   Dr. Burns notes the same issue arises when he considers OTC supports. He approaches this issue by sharing his thoughts with the patient and encouraging the patient to let him make another attempt at orthotic control before moving on to more aggressive treatment plans.

   In 25 years of experience with computer assisted gait analysis, Dr. D’Amico has found most of these faux “orthotics” increase the weightbearing surface, increase shock absorption, decrease stability and do not improve objective gait parameters. He adds that these devices may produce asymmetrical pathologic alterations in weight distribution patterns through the ankle, knee, hip and spine.

Q: What is the earliest age you would prescribe functional foot orthoses for a child? What conditions would you most typically be treating?

   A: Dr. Levine does not determine orthosis use by age but by symptoms and/or pathology. He advises starting out with OTC devices and tracking progress. If this is not sufficient, then custom devices are necessary, according to Dr. Levine.

   Dr. Burns uses an OTC support until the child is about 5 years old. He feels that when youngsters can walk down the stairs one step at a time without holding on to the handrail, they have developed a propulsive phase. Dr. Burns notes this may be a useful milestone to determine when functional orthotic control may be adequate. More often than not, he uses some type of deep heel cup and high medial flange along with a functional device for children. Dr. Burns notes this combination seems to help keep them “on top” of the device.

   When it comes to children, Dr. D’Amico most commonly treats excessive pronation, which may be the result of a variety of conditions but probably the most common would be developmental flatfoot. He starts treatment as soon as the child is able to achieve unassisted stance at 7 to 9 months of age. At this time, the immature and malaligned osseous infant foot framework begins to be susceptible to the deforming effects of gravity, according to Dr. D’Amico.

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