Despite the success rate one may have with orthotic devices, sometimes patients may not tolerate the devices. These expert panelists discuss treating patients who do not tolerate orthoses, when orthoses need to be replaced, which orthotic materials may lead to success and how shoes affect orthotic function.
How do you handle patients who do not tolerate or find comfort from the orthotic devices that you fabricate regardless of the adjustments made?
As David Levine, DPM, CPed, notes, one can use a variety of approaches with patients who have trouble tolerating orthotic devices. Although such challenging situations do not arise very often, he says not every patient will tolerate orthoses and one should have a protocol to follow when this does occur. The podiatrist’s objective findings and clinical expertise must be in harmony with the patient’s subjective orthotic wearing experience.
“Matching objective and subjective situations is sometimes very challenging,” notes Dr. Levine.
Orthoses sometimes do not function as well as the doctor intended. Dr. Levine says one can attribute this to the casting technique or orthotic materials. For example, when it comes to a patient with a very flexible midtarsal joint in the sagittal plane, Dr. Levine notes a typical suspension casting technique may not work as well as when one casts someone prone in this position. However, regardless of the casting technique and material selection, Dr. Levine says making adjustments to the orthoses is sometimes necessary. Typically, he notes that if two adjustments do not provide a satisfactory result, it is necessary to remake the orthosis.
Robert Warkala, DPM, tries to be as specific as possible when matching appropriate clinical symptoms to the orthotic’s materials and style. When it comes to patients who cannot tolerate the devices after multiple adjustments, he reduces the amount of correction in the body of the orthotic.
Ray Fritz, DPM, CPed, says it is “a very rare event” for his patients not to tolerate his devices. He praises the orthotic lab he uses and says returns to the lab are rare. Dr. Fritz concedes that adjustments are occasionally necessary and he can do minor adjustments in the office if necessary. He says multiple adjustments are “extremely rare.”
“Tough cases require time and thought but are well worth it for a winning outcome,” says Dr. Fritz. If a device totally fails to contribute to a patient’s comfort, Dr. Fritz starts over and chooses different materials, noting that the expense is minimal since it rarely happens in his practice. He believes there is a device that will provide comfort for every patient and notes the challenge of selecting the best materials and fabricating the best device for each patient.
“Patients have individual goals and desires,” says Dr. Fritz. “It is important to understand their expectations before setting the orthotic plan in motion.”
Depending on the shoe styles that patients are willing to accept, Dr. Fritz notes the patients themselves may also pose some obstacles. For example, he says some patients are resistant to change and insist on wearing dress shoes that do not have much room for an orthotic. He adds that thin graphite orthoses are best for dress shoes. In difficult cases, patients who complain that an orthosis is too hard may more easily tolerate softer orthotics made from accommodative materials or at the very least a combination type device, according to Dr. Fritz.
Dr. Warkala says patients who fail orthotic therapy after multiple adjustments get a refund of any money and the orthotics are discarded. Since devices are custom-made, Dr. Levine says one should offer a guarantee to the patient. He says the guarantee should state that the patient will be more comfortable with the orthotic devices than without or he or she will get a refund.
Dr. Fritz has never had to refund a patient’s money. He says there is always an option or orthotic type that the patient will find comfortable. Dr. Fritz finds it “much more rewarding to proceed with a second attempt in spite of the time to achieve the successful outcome. Successful outcomes in difficult cases are always priceless in terms of the reputation of the practice and future referrals.”
How do you determine when orthotic devices need to be replaced other than in situations where they are obviously worn out or broken?
Dr. Fritz says if a problem is significant enough to require an orthosis, it is worthwhile to reevaluate the orthosis a year later. He uses one year as a follow-up time since he feels orthotic labs should generally guarantee their work for at least a year. At the follow-up visit, he evaluates the patient, the problem and the orthotic, which may have some changes due to wear. Dr. Fritz says DPMs may address orthotic changes or repairs during the follow-up, noting that patients often request a new orthotic during that visit.
“Most patients in my experience would rather proceed and have a second pair of orthotics fabricated rather than give up their old orthotics for repairs even though it may only be for one week,” says Dr. Fritz. “People appreciate the benefits of their orthotic devices and are rarely willing to part with them even for a short period of time.”
The clinical symptoms of the patient will usually indicate whether one needs to evaluate the orthotics for refurbishing or replacement, according to Dr. Warkala. Often, he says one can easily replace the heel post to help reduce the patient’s discomfort, adding that the podiatrist should place the orthotic against the foot to ensure adequate contouring.
The lifespan of orthotic devices varies, says Dr. Levine, noting some patients require replacement of devices more often than others. As he points out, some patients will present with orthotic devices that are over 15 years old and they are still holding up well. He advises comparing the positive casts (which one can dispense with the orthotic devices) to the orthotic devices themselves. If the orthotic device no longer conforms to the cast, Dr. Levine says the shape of the orthosis may have changed enough to require fabrication of new devices. If new biomechanical complaints arise, he notes this may also warrant making new orthotic devices.
Dr. Fritz reminds that patients often keep old orthotics as back-up devices that they use sometimes for less demanding activities. He notes patients do choose additional orthotics.
“I believe in this day and age people are engaged in many activities and they often have many shoe styles,” says Dr. Fritz. “No one orthotic is perfect for all activities and all shoe styles.”
In addition, having two or three types of orthotics increases the spectrum of shoes that an individual can wear. As Dr. Fritz mentions, acrylics and graphites are sleek enough to fit in almost any shoe while patients may sometimes reserve full-length composites for heavy duty working environments as well as various sports.
Dr. Fritz’s discussions with patients do not center around the functionality of one device. He emphasizes increasing the range and use of orthoses as opposed to replacement. Dr. Fritz says clinicians should avoiding replacing something that works and encourage patients to upgrade and expand into a new orthotic that may better address a specific need in regard to activity or shoe fashion.
Dr. Fritz notes his children have sports orthotics for basketball as well as orthoses that work well with school shoes. “I have given them options and, in return, they have given me an education and insight into pros and cons associated with different devices,” notes Dr. Fritz.
How does a shoe affect the function of an orthotic device?
For Dr. Warkala, the shoe is the base of the support for the orthotic. As he says, excessively worn shoes create motions that are not desirable for the entire lower extremity as well as the orthotic. He recommends that patients keep a close eye on how their shoes are wearing and how their previously painful conditions are doing.
“No matter how perfect an orthotic device is, it is only as good as the shoe in which it is placed,” asserts Dr. Levine. “In my opinion, shoes cannot be emphasized enough to our patients.”
When writing orthotic prescriptions, Dr. Levine says DPMs often focus on degrees of varus, valgus and rearfoot post motion. However, he says this is all completely negated if the shoe is inappropriate or excessively worn. Dr. Levine emphasizes that the shoe needs to function with the foot, not against it, and that custom molded orthotic devices must fit the foot as desired. He adds that the orthoses also need to fit the shoes and he says this can sometimes be an issue depending upon the shoes patients select. Once the physician has addressed all of these factors, Dr. Levine says there is a very good chance of achieving the initial treatment goals.
Dr. Fritz cites a patient with a severe hyperpronated foot type. He says the well intended and designed orthotic devices for such a patient may be lost if one places the device in a thin, soled “bobo” style sneaker. He says a straight, wide lasted sneaker (such as the New Balance 1122, Brooks Beast or Brooks Addiction) will provide a wider base of support for the orthotic and the patient’s foot. Dr. Fritz says the shoe last must conform to the patient’s foot, noting that straight lasted and curve lasted shoes can add to the orthotic benefit and to the overall fit.
Patients with diabetes need extra depth shoes with accommodative features, according to Dr. Fritz. He says shoe rigidity, sole materials and counter materials may add to the function of the orthotic in controlling abnormal foot motion. Dr. Fritz encourages clinicians to take the heel height of the shoe into account with the fabrication of the orthotic device, especially when it comes to women’s fashion, in order to allow for proper seating and post elevation.
Dr. Fritz emphasizes communication with patients about problems and expectations.
“The discussion increases orthotic success in any practice. The days of fabricating an orthotic and handing it to the patient to deal with the shoe fit problems are over,” says Dr. Fritz. “The podiatrist who understands the interrelationships between shoes and orthotics will have more successful outcomes. Communication, education and understanding between the podiatrist and the patient are paramount for success.”
Rohadur had been the material of choice many years ago. How often do you use a material that rigid now for your patients? If you do use rigid materials, how do you decide when to use them?
In general, Dr. Levine says rigid devices will be successful in situations in which the patient has a lot of subtalar and midtarsal joint flexibility as rigidity provides more control of the foot. Materials such as Superglass, TL2100 and others provide the rigidity needed, according to Dr. Levine. He notes the contour of the orthotic device also contributes to rigidity. In a foot with a low arch, materials do not function as rigidly as in a high arched foot, explains Dr. Levine.
Depending on the rigidity needed, Dr. Levine says polypropylene is one of many materials that can work well. He adds that different thicknesses of polypropylene indicate different rigidities. Although there are conflicting findings in the literature, Dr. Fritz says many feel rigid materials including polypropylene are superior for control. He uses a rigid component or at least a semi-rigid component in 75 percent of all the orthotics he fabricates in his office. The semi-rigid component often can be a thin polypropylene shell that will help eliminate deformation, according to Dr. Fritz.
Dr. Warkala uses rigid materials like carbon fiber composite materials for about 5 to 10 percent of his patients. He bases the decision to use rigid materials on biomechanical exams as well as the types of shoes in which the orthotics will be worn.
Dr. Fritz cites other materials such as the graphite materials provide excellent support. Dr. Fritz uses graphite rigid materials less than 40 percent of the time as an exclusive orthotic material. He frequently selects these materials for biomechanical control and notes they fit well in fashionable shoes. Dr. Fritz says the two main reasons for the exclusive use of rigid materials are for functional control of foot deformities and that rigid materials take up very little space in a shoe. Dr. Fritz notes patients will often choose combination materials and cushioned top covers for overall comfort and specific sports activities while some patients prefer full-length orthotics and an extra element of cushioning. He selects orthotics based on the symptom complex and pathology, foot type, sports activity and shoe style. Ultimately though, Dr. Fritz says the patient chooses the orthotic based on performance and comfort.
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. Fritz practices at Allentown Family Foot Care in Allentown, Pa. He is a Fellow of the American College of Foot and Ankle Surgeons.
Dr. Warkala practices in Sewell, N.J. He is certified in primary podiatric medicine by the American Board of Podiatric Orthopedics and Primary Podiatric Medicine.
For related articles, see “Secrets To Fabricating Custom Orthotics” in the June 2004 issue of Podiatry Today or “Key Insights On Orthotic Materials” in the September 2003 issue.
Also check out the archives at www.podiatrytoday.com .