Are orthotics prescribed too much or are they underutilized when it comes to biomechanical issues in the lower extremity? In addition to emphasizing a tailored treatment approach for each patient, these experts also detail their casting methods and the standards they use to choose orthotic fabrication materials.
None of the panelists believe in making a blanket prescription for orthoses to every patient. Nicholas Romansky, DPM, suggests the over-prescribing of orthotics can lead to a bad rap for podiatry. Kevin Kirby, DPM, concurs.
“I don’t know of any ethical podiatrist who would recommend foot orthoses, either prefab or custom, to every patient,” says Dr. Kirby.
Any treatment recommendations should be geared toward either resolving pathologies that are causing pain and disability, or preventing pathologies from occurring or becoming worse in the future, according to Dr. Kirby. David Levine, DPM, CPed, maintains that orthotic devices represent one step in, what is for most people, a gradual treatment process.
As part of that process, Dr. Levine suggests starting with a shoe assessment in order to make sure the patient is wearing a type of shoegear that is functionally appropriate. He often proceeds to have the patient try an over-the-counter (OTC) device. If that OTC device is not successful enough, Dr. Levine says the next logical step would be custom orthoses. However, he notes there are some patients who will not tolerate OTC devices so one might need to skip prefabs in these situations and go directly to custom orthotic devices.
“The bottom line is that it is a case by case, situation by situation determination,” notes Dr. Levine.
Drs. Kirby and Romansky agree that often in order for orthoses to be successful, one must customize the devices to the individual patient.
Dr. Kirby recommends custom foot orthoses to many of his patients. He notes that well-made foot orthoses are frequently “the most cost-efficient and therapeutically effective treatment options that are available to treat mechanically-based foot and lower extremities pathologies.” Like Dr. Levine, he often recommends that patients first purchase prefabricated orthoses, which he subsequently modifies in his office, either as a primary or temporary treatment measure.
Dr. Romansky does note that when patients need orthotics, the devices can not only benefit the lower extremity but the back, hips, knees and other areas as well.
“(Orthoses offer a) universal product that we can use for so many things,” says Dr. Romansky.
Dr. Kirby adds that the medical profession is currently “underutilizing” well-made custom foot orthoses to treat the great many mechanically-based pathologies of the foot and/or lower extremity that occur.
As Dr. Levine notes, casting for orthotic devices depends upon many factors such as the goal of treatment, the type of device one is fabricating, the shoes the patient will wear and the activity level of the patient. Similarly, Dr. Romansky suggests considering the patient’s shoegear, height, weight, occupation and, most importantly, the problem one is treating.
Although it is common to cast while the patient is supine with the neutral suspension technique, Dr. Levine notes the technique does not work for everyone. He says some patients need to be cast while prone and some need to be cast while they are in a semi-weightbearing position.
“Weighing all of the variables, doing a thorough biomechanical exam and determining the goal of treatment will help decide the best way for the patient to be casted,” emphasizes Dr. Levine.
Dr. Kirby uses the same negative casting method for making custom foot orthoses that he learned from his biomechanics professors at the California College of Podiatric Medicine both as a student and as a biomechanical fellow. This entails the supine neutral position suspension casting technique with plaster splints. As he elaborates, his casting technique involves loading the lateral column at the fourth and fifth digital sulcus in a dorsiflexion direction while placing the subtalar joint in the neutral position.
Over the last 27 years, Dr. Kirby has used numerous modifications of this classic casting technique depending on the patient’s specific pathology, foot structure and his or her predominant weightbearing activity. His common modifications include plantarflexing the medial column to increase arch height, dorsiflexing the medial column to decrease arch height and/or casting with the subtalar joint pronated from neutral.
The two main types of orthosis shell materials that Dr. Kirby uses for custom foot orthoses are polypropylene and high-density polyethylene foam such as Plastazote #3. In 27 years of fabricating more than 15,000 pairs of orthoses for his patients, he has found polypropylene to be “by far the most durable and fatigue/breakage resistant orthosis material available.” His patients will routinely return to his office with polypropylene orthoses that are over 10 to 15 years old and show little sign of wear or flattening.
Dr. Kirby says one can use Plastazote #3 orthoses to treat distance runners who weigh less than 180 lbs., as well as pediatric and adult soccer players. As he notes, other uses for Plastazote #3 include treating chronic plantar heel pain for patients who walk and stand on hard surfaces all day. Patients should replace Plastazote #3 orthoses every four to five years due to the gradual compression set that occurs with this lightweight orthosis material, according to Dr. Kirby.
Dr. Levine bases his material selection on the type of shoes the patient wears, the foot structure, the range of motion and the goal of treatment. There are some patients who might do well with a semi-rigid material for everyday use but if these patients run, he suggests a softer, more supportive device might be necessary.
Likewise, Dr. Romansky bases the orthotic material on the patient needs and using common sense, noting that one would not put a 400-lb. patient in graphite because the device would break. He also factors in if he will heat or mold the material. For example, Dr. Romansky says graphite can only stand so much heat before it breaks.
Furthermore, Dr. Romansky suggests using multiple labs as not all labs are created equally. As he notes, not every lab offers the same material, some labs are more specialized than others and some labs cost more.
“Podiatrists need to hybridize or customize because they have a lot of options now,” says Dr. Romansky.
Dr. Kirby is an Adjunct Associate Professor within the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University in Oakland, Calif. He is in private practice in Sacramento, Calif.
Dr. Levine is a Fellow of the American Academy of Podiatric Sports Medicine. He is in private practice and is the director and owner of the Frederick, Md.-based Walkright and Physician’s Footwear, a fully accredited pedorthic facility.
Dr. Romansky is a Fellow of the American College of Foot and Ankle Surgeons. He is in private practice at Healthmark Foot and Ankle Associates in Media and Phoenixville, Pa.