Pearls On Getting Orthotic Prescriptions Right For Patients

Guest Clinical Editor: David Levine, DPM, CPed

Our expert panelists discuss the importance of biomechanics in their practices and expound on how to properly apply biomechanic principles with orthotics as well as how to remake devices when patients complain that the orthoses are not right for them.


How has the way that you apply biomechanics in your practice changed over the last 10 years?


David Levine, DPM, CPed, cites several reasons for changes in applying biomechanics in his practice. “Having my own orthotic lab puts me in closer touch with the entire process from casting to dispensing to how the patient is functioning,” he explains.

   Dr. Levine notes that not all of the biomechanical theories DPMs learn in school have practical day-to-day applications.

   “Obtaining knowledge from as many sources as possible including Root biomechanics, pedorthic philosophies and even other specialties such as physical therapy and from orthotists has taught me that an open mind is very important,” asserts Dr. Levine. “We do not know it all and need to continue to learn.”

   Over the years, Adam Spector, DPM, notes that incorporating biomechanics into his podiatry practice has taken on greater importance. He says nearly every evaluation of musculoskeletal-related pain in his practice involves at least a brief gait examination and he uses a treadmill to evaluate runners as well.

   Gene Mirkin, DPM, notes that early in his career, he did what he learned to do in residency, and was more focused on surgery. However, he came to the realization that not every patient was a surgical candidate and that biomechanical solutions can sometimes resolve the issue at hand.

   “ … Many of the problems we see on a regular basis really do respond to mechanical alterations,” maintains Dr. Mirkin. For him, biomechanical control, through the use of strappings and orthotics, has become a precursor to surgical intervention. When patients fail to respond to this approach, he suggests surgery as a possible next option.

   Furthermore, Dr. Levine emphasizes that listening to patients and their complaints is critical. He notes that with so many avenues available for patients to utilize self-treatment, they are presenting to practices with more technical information about what works, what does not work and what they have already tried. This has forced Dr. Levine to rethink and change how he applies biomechanics in his practice.

   “With the cross pollination and overlap of other medical professionals such as physician assistants, nurse practitioners, physical therapists, orthopedic surgeons and even generalists into the foot and ankle realm, our knowledge of biomechanics and its relationship to foot and ankle pathology is what sets us apart,” says Dr. Spector. “The successful resolution of injuries as well as positive surgical outcomes can only be consistently achieved by taking into account lower extremity biomechanics.”


What changes have you made in prescribing orthotic devices over the last 10 years?


Technological advances have allowed Dr. Mirkin to get away from plaster casting techniques that he calls “tedious, time-consuming and messy.” He first changed to two-dimensional scanning with weightbearing. Although this saved time, he says the inability to capture the subtle deficiencies in the technology, so obvious in plaster molds, was overshadowed by the “wow factor” of scanning and the time he saved using this new system.

   When he finally upgraded to the non-weightbearing, three-dimensional scanning technology, Dr. Mirkin acknowledges the mediocrity of the weightbearing scanners became obvious. After the learning curve of using this system, he cites a significant reduction in the number of devices returned for adjustment with this new technology. Dr. Mirkin says his accommodative modifications were much more accurate.

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