Insights On The Evolving Nature Of Orthotic Education And Casting

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

   Dr. Phillips notes his alma mater was able to only do so much in regard to biomechanics education. He says the dedication of the aforementioned orthotic laboratory improved the orthotic prescribing practices of those in the profession. Although the Prescription Foot Orthotic Laboratory Association (PFOLA) was supposed to bring the same dedication to the entire profession, he notes this has failed to materialize in the last few years. Part of the problem, says Dr. Phillips, is that it is difficult to learn biomechanical principles and practices in large lecture halls. He suggests that podiatrists can best learn this in small groups.

   Dr. Phillips also cites the influence of his father, a podiatrist who was interested in biomechanics, and who noted that it was not unusual for practitioners who wanted to learn biomechanics to visit and work with other practitioners who were considered more expert in this arena. If he were a young doctor today, he would contact known experts who are seeing 10 or more orthotic patients per day, and watch and assist in their offices. Although there is no CPT code to bill for such time and many people may not want to teach because they may feel slowed down, Dr. Phillips argues this is the only model that seems to have worked well in the past.


What is the most common question you get from practicing podiatrists who seek your consultation for specific prescriptions?


For Dr. Scherer, the most common orthotic prescribing questions, from clients or students, fall into eight categories or pathologies. These are adult-acquired flatfoot, plantar fasciitis (with and without an everted heel), functional hallux limitus, pediatric flexible flatfoot, pes cavus, metatarsalgia, tarsal tunnel syndrome and medial knee pain. He notes most reputable orthotic laboratories produce a specific orthotic designed for each pathology rather than a generic device that is designed for the age, shoe or activity of the patient.

   Colleagues are often frustrated by trying to understand why the orthotics they order are not alleviating symptoms, notes Dr. Phillips. He finds one of the most common problems is that practitioners do not perform basic biomechanical examinations. These podiatrists learned that the symptom is supposed to respond to orthotics yet he notes when you question them about the specifics of their patient, these physicians lack any information about the basic biomechanical examination. In fact, Dr. Phillips notes many practitioners prescribed these orthotics without doing any type of biomechanical examination.

   Many years ago, a residency director told Dr. Phillips that he could write the book “Everything You Need to Know in Biomechanics” with one sentence: “Take a neutral cast.”

   “I laughed at the time because I thought he was making a joke but I now find that a great many practitioners believe this is true,” says Dr. Phillips. As a result, he notes that many practitioners (or their staff members) take a cast and send it to the laboratory, expecting the laboratory to figure out how to make the orthotic. If the orthotic comes back and does not work right away, then these practitioners believe it must be the laboratory’s fault or it must mean that orthotics cannot work for the patient and some other type of therapy is necessary, notes Dr. Phillips.

   Dr. Smith most frequently hears questions about the appropriate flexibility or rigidity for a patient of a given weight with little consideration for activity, foot gear, sport or a specific foot type, all of which are pertinent factors to the flex of the orthotic. Oddly, he says some are apprehensive of the more rigid flexing devices because they equate softness with comfort and equate rigidity with discomfort. As Dr. Smith explains, rigid orthoses help realign the foot and the immediate suprastructure, and these positional changes are not possible with pliant foot devices. Pain relief is primarily a direct or indirect function of improved alignment and function, according to Dr. Smith.


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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