Insights On The Evolving Nature Of Orthotic Education And Casting

Author(s): 
Guest Clinical Editor: Doug Richie Jr., DPM, FACFAS

   Furthermore, Dr. Phillips notes if one asks students to explain how any surgery changes the leverage effects of the foot, “you will get a blank stare.” He notes a few instructors have tried to introduce to the profession the clinical identification of the subtalar joint axis, an identification that he totally supports. “Yet even these brilliant minds are focusing on the foot as if the foot were a solid block of wood between the subtalar and the metatarsophalangeal joints,” says Dr. Phillips.

Q:

How can young practitioners who lack skills in casting and prescribing custom foot orthoses obtain further knowledge and training?

A:

As Dr. Phillips recalls, he had a great difficulty in learning orthotic casting instruction when he was a student. When a group of students from his graduating class of 1979 felt frustrated that they weren’t learning casting well, he recalls making an appointment with Merton Root, DPM, where they spent four hours with the master caster himself, learning his technique. He specifically remembers spending half the time learning to position the patient properly, saying without proper patient positioning and the proper physician posture, it would be impossible to make a good cast. After graduation and taking specific biomechanics clinics in which he built the orthotics himself, Dr. Phillips recalls having much to learn. In those days, he notes a great many practitioners still made their own orthotics in their offices or in little laboratories they built in their garages.

   “I want to say that if you really want to learn orthotic practice concepts, do your own casting and build the orthotics yourself,” says Dr. Phillips. “By doing so, you really do find what works and what does not. I have had few, if any, patients refuse to wear orthotics because they were not perfectly polished. In fact, when I was in private practice, I could tell if a person was wearing his or her orthotics by how well his or her socks were polishing the plastic.”

   Dr. Phillips recalls using the Root Lab for a few orthotics and says Dr. Root would do an annual seminar free of charge for anyone who used his laboratory. These seminars never offered any CME credits but he says they were invaluable in learning what was working for others as well.

   “It was truly one-on-one teaching that is almost impossible to find anywhere today,” he says. “I have been the beneficiary of a person who built a small orthotic lab dedicated mostly to making the profession better and only secondarily to making a profit.”

   Dr. Smith says the skills to cast a foot with the subtalar joint neutral and the midtarsal joint locked are difficult because this procedure is both a science and an art that requires skilled professional guidance. With practice, he notes one can obtain positional skills but maintaining that alignment while the plaster cures is an additional challenge. As the practitioner fatigues, the foot drifts into a supinated position, which he believes is the most significant cause of orthotic discomfort and failure.

   However, Dr. Smith notes the new digitizers and scanners “offer a great hope” for that problem because maintaining proper foot position/alignment requires minimal time, ranging from an instantaneous flash to an approximately 15-second scan.

   There is minimal formal post-graduate biomechanical learning because very few seminars include appropriate lectures, even at state seminars officially sanctioned by the American Podiatric Medical Association, according to Dr. Smith.

Comments

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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