Pearls On Getting Orthotic Prescriptions Right For Patients

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

   “I couldn’t go back to plaster now and the benefit of the weightbearing scanners is just not accurate enough to go back to that technology either,” says Dr. Mirkin.

   In the last decade, Dr. Levine notes that orthotic materials have moved from Rohadur to polypropylene to a variety of materials made from different casting techniques. He has learned there is more than one right way to provide biomechanical solutions for patients, saying that different devices can function similarly. He emphasizes that one should listen to patients and make sure they know that dispensing a device does not mean they are now on their own. Indeed, Dr. Levine says devices sometimes need management depending upon the patient’s activity level, shoe selection and symptoms.

   Dr. Spector, who still uses “old school’” plaster casting methods to ensure the most accurate impression of the foot, relates that his modified, basic semi-rigid sports type orthotic has sufficed for the majority of his patients over the years. His specific prescription varies greatly, however, to accommodate for the patient’s diagnosis and individual characteristics and preferences. He listens more carefully to his patients’ needs and shoe specifications to ensure optimal performance and shoe fit.

Q:

What do you do when patients complain that their orthotic devices are too rigid?

A:

Dr. Spector explains to patients that prescription orthotics are corrective braces designed to maintain long-term correction and prevent recurrence of symptoms once the acute pain has resolved. Usually, if the orthotics are not comfortable, he explains that the acute pain has not adequately resolved and needs additional treatment such as physical therapy, injections or nonsteroidal anti-inflammatory drugs before the orthoses will work. Dr. Spector will modify rigid orthotics or substitute more accommodative devices only after he is confident that the acute pain is under control.

   As Dr. Levine notes, the most important thing is to listen to the patient and then figure out why the device is too rigid. Is it a foot with a restricted range of motion that needs more shock absorption? Is it related to shoe selection? He says focusing on only one type of device without analyzing the patient’s needs can lead to a complaint of a rigid device. Dr. Levine likens this to performing an Austin on every bunion — some will fail but some will do great. He stresses the importance of picking the right material for each patient and adds that having his own lab enables him to work with patients more liberally if a remake is necessary.

   If patients have followed all of Dr. Mirkin’s break-in instructions and still complain that the devices are too rigid, he remakes the orthoses as more flexible devices at his own cost.

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.

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