Insights On The Evolving Nature Of Orthotic Education And Casting

Guest Clinical Editor: Doug Richie Jr., DPM, FACFAS

Acknowledging changes in the way podiatry students learn orthotic therapy, these experts discuss how such changes affect the quality of casting, and how young practitioners can gain casting experience. They also discuss common questions from prescribing podiatrists and debate the value of over-ground weightbearing scanners.


Has the decline in the formal teaching of foot orthotic therapy at schools of podiatric medicine affected the quality of casts and prescriptions submitted to labs?


Noting that while he does not own a laboratory or have financial connections with any laboratory, Robert D. Phillips, DPM, says he does notice that young practitioners have little idea of casting theory. As he says, the only textbook to deal with orthotic casting has been out of print for many years.

   As a result, fewer and fewer practitioners can explain Root casting theory, how it developed and how it facilitates normal foot function, according to Dr. Phillips. He says some practitioners have adopted the idea that DPMs are creating an arch support, a model of what the foot is supposed to look like, and if one props the orthotic into this position for a while, after removing the prop, the foot will continue to look the same.

   “The decline in teaching foot orthotic/biomechanical theory in both the classroom and clinic has degraded not only the quality of the casts but also the understanding and expectations of the practitioner,” claims Christopher Smith, DPM.

   Since many practitioners lack experience with negative casting, Dr. Smith feels they may simply defer the casting procedures to office assistants or CPeds. He says this reflects a “gross indifference” to casting, which he says requires both art and science.

   “At best, this is simple dilution of knowledge and skill, somewhat motivated by office economics but more importantly, it reflects a failure of the profession at large to appreciate the significance of a good cast of the foot,” asserts Dr. Smith.

   Paul Scherer, DPM, has not seen a decline in quality negative casts or scans at ProLab Orthotics but notes his orthotic lab only accepts non-weightbearing plaster or fiberglass casts or scans that capture the posterior surface of the calcaneus and a forefoot to rearfoot relationship. However, he does note seeing a large increase in new clients, particularly from the East Coast, who want to send crush boxes for functional orthotics, which the company declines.

   “It is obvious that these practitioners do not understand the concept of how orthotics are intended to prevent subtalar or midtarsal joint compensation to decrease tissue stress,” says Dr. Scherer. “I believe their instructors or orthotic manufacturers may have told them that a proper functional device can be made from an impression of the foot in a pathologic position. I do not believe this is possible.”

   In exhibit halls, Dr. Scherer has heard manufacturers telling practitioners that a lab can make a proper three-dimensional functional device from a two-dimensional pressure mat or scan. He says this idea is just as much an illusion as the technique of touching the full plantar aspect of a foot to the glass plate of a foot scanner. He feels it’s not the schools that are teaching this concept but rather that practitioners have succumbed to “the nonsense perpetrated by financial opportunists and amateurs who work outside of academia.”

   Dr. Phillips acknowledges a rise in the number of individuals who are determined to return to the pre-Root era of arch supports. He says this leaves young professionals confused by a number of competing theories on biomechanics and teachers (especially at the post-graduate level) who do not want to be bothered trying to sort out fact from fiction.


The reason so many orthotics do not reduce symptoms is that those feet are attached to a body and a pelvis that may not tolerate what the orthotics try and make the feet do. Podiatrists should work with skilled orthopedic physical therapists to determine and work with patients who have restrictions and imbalances elsewhere in their body.

There are numerous pedorthic programs across the country. I took one at Temple that was only 2 weeks. Great class. Young podiatrists should seek out those programs to learn how to cast and how orthotics are made instead of relying on a lab that will never see your patient's foot nor do they want to.

In response to MB's comment:

Pedorthotic programs are good and I do avise you learn as much as you can from them. However, they will not be able to teach you how to cast for a "Root functional orthotic" nor teach you the theory that they are built on. You should use such programs to add to your knowledge base, not to replace it.

As to the need to work with physical therapists, again that is important, however the podiatrist should be trained to also fully examine the patient for restrictions in movement. We expect the podiatrist to learn to do a complete H&P because we want podiatrists to do their own admissions to hospitals. Why shouldn't a podiatrist know how to fully examine a patient for abnormalities that create gait limitations? Are we not the "gait experts?"

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