Pearls On Getting Orthotic Prescriptions Right For Patients

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Author(s): 
Guest Clinical Editor: David Levine, DPM, CPed

Q:

Do you ever have to remake orthotic devices due to patient complaints? If so, why do you think that happens?

A:

If one makes enough orthoses, Dr. Levine says there will inevitably be complications as it is impossible to make the perfect orthotic for everyone. He notes the key is addressing complications before they happen. Dr. Levine suggests explaining to the patient that orthotic devices should be like glasses. You can go to the drugstore, buy reading glasses and definitely see better but he says if you want the best possible vision corrected for each eye, you need a prescription. Dr. Levine says the same is true for OTC orthoses. They should be very comfortable for both feet, according to Dr. Levine.

   First, Dr. Mirkin applies strapping to all his patients. If patients benefit from the short-term control offered by a low-Dye strapping, he says the odds are “overwhelming” that they will benefit from an orthotic. However, he does acknowledge there are the occasional patients who just don’t like the way their devices feel. Dr. Mirkin always initially tries to modify the orthoses himself. However, if the devices look like they fit well and offer the correct fit and control, and the patient is still not happy, he will remake the orthoses.

   Most of the time patients are unhappy with their devices when one chooses the wrong material or due to poor scanning technique, according to Dr. Mirkin. If one does not hold the foot against the glass in subtalar neutral, he says the scan is skewed and one must redo it. At times, Dr. Mirkin says his additions (like a Morton’s extension or metatarsal pad) seem like a great idea but are not so he must make adjustments.

   “The usual scapegoat, lab error, has really been taken out of the equation with the new scanners and knowledge of the right labs,” notes Dr. Mirkin.

   Prior to remaking devices, Dr. Levine advises podiatrists to ensure that the patient is wearing appropriate footwear that not only accommodates the devices but will enable the foot to function efficiently. He also says ensuring all the basics are covered before remaking orthoses is helpful. In order for the foot to function efficiently, the shoe and the foot need to work together. For example, he suggests holding the shoe in your hands to check where the shoe flexes. Dr. Levine says the flex point of the shoe should be at the ball of the foot so when entering propulsion, resistance will be minimal. If the break point is anywhere else, he notes more energy from the foot to overcome the shoe will be necessary. Then if a remake is needed, Dr. Levine says patients “will have a better understanding of what they should expect, but also have even more confidence in your care when you show them how you stand behind your work and what you produce.”

   Dr. Spector rarely has to remake orthotics, citing good quality control and checking orthotic casts before sending them to the lab. He listens carefully to patient preferences initially but sometimes patients will change their mind and shoe preferences so he will try to be creative and flexible to make it all work. Dr. Spector has previously sent the patient’s shoe or previous orthotics to the lab to find the right combination.

   “In the end, I try my best to make my patients happy, which may involve a little trial and error with a cooperative lab,” says Dr. Spector.

   Dr. Levine is in private practice and is also the director and owner of Physician’s Footwear, an accredited pedorthic facility, in Frederick, Md.

   Dr. Mirkin is board certified in foot surgery by the American Board of Podiatric Surgery and board certified in foot and ankle orthopedics by the American Board of Podiatric Medicine. He is a Fellow of the American College of Foot and Ankle Orthopedics, and a Fellow of the American Society of Podiatric Surgeons. Dr. Mirkin is in private practice in Maryland.

   Dr. Spector conducts bimonthly multispecialty running clinics. He is board certified by the American Board of Podiatric Surgery and is a Fellow of the American Society of Podiatric Surgeons. He is in private practice in Maryland.

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