Inside Insights On The Evolution Of Orthotic Therapy
Over the last decade, there have been a variety of changes and trends that have shaped the evolution of orthotic therapy. Accordingly, our expert panelists discuss pertinent orthotic prescription trends. They also examine the importance of having a strong background in biomechanics and whether the podiatric profession is “giving away” its biomechanics expertise to non-podiatric physicians. Q: What specific changes have you observed in the overall utilization of functional foot orthoses in the typical podiatric practice in the past 10 years? Are orthoses still an important part of the treatment armamentarium of the typical podiatric physician? A: During the past decade, Chris Smith, DPM, says the number of orthotics used by podiatrists has “expanded dramatically,” judging by the increased volume of foot orthotics manufactured and the number of new orthotic labs. He notes the use of orthoses is experiencing a “strong upward trend” after appearing to plateau for two or three years. Both Paul Scherer, DPM, and Douglas Richie Jr., DPM, note growth in the use of custom foot orthoses (CFOs) in the last 10 years. Dr. Scherer attributes the more frequent usage of CFOs to more literature demonstrating the devices’ efficacy. He notes that DPMs who utilize good casting methods and prescription writing have improved results and have accordingly elevated their reputation among other podiatrists. Dr. Richie ascribes the growth in custom orthoses to the fact that non-DPMs, such as orthotists, pedorthists and physical therapists, are using the devices in increasing numbers. He believes younger DPMs are not prescribing custom devices as often as those who have been in practice more than 10 years. Additionally, Dr. Scherer has seen a change in DPMs prescribing more pathology-specific CFOs. As he explains, fewer podiatrists are prescribing orthoses solely according to a patient’s age or sports activity and more are basing prescriptions on the patients’ specific needs or the pathology that is causing the dysfunction. Q: What changes or new trends have you seen in terms of orthotic materials that are used in prescriptions? A: As Dr. Scherer sees it, today’s orthotic trends do not involve manufacturing materials. He notes that polypropylene and graphite composite comprise 98 percent of the custom orthotics that are made. However, he sees increased utilization of cast correction methods including the medial skive, inverted positive technique and orthotic additions such as reverse Morton’s extensions and distal end metatarsal bars. Likewise, Dr. Richie has not seen any breakthroughs involving orthotic materials in the last 10 years. He feels that polypropylene and composite materials have been used consistently. When he first entered practice, the only type of orthotic was basically a Rhoadur shell with an acrylic post, top cover or extension. These days, he notes most orthotic prescriptions include some type of top cover and full-length extension. New trends include “dress style” orthotics and custom sandal orthotics, according to Dr. Richie. Dr. Smith says the profession is slowly beginning to use more pathology-specific devices like the Richie Brace and the posterior tibial dysfunction device. He has also seen more use of rearfoot posts and forefoot extensions. Q: Overall, how has the quality of negative casts or quality of the prescriptions from podiatrists changed over the past 10 years? A: Dr. Scherer has seen a significant change in negative casts, noting that some podiatrists take impression casts that invert the forefoot on the rearfoot or dorsiflex the first ray. He emphasizes that DPMs who have found success with orthotic therapy employ pathology-specific orthotic prescription writing. After five years of visiting or lecturing at all the schools of podiatric medicine, Dr. Richie feels some have neglected the art of casting, noting a deterioration in the quality of impression casts submitted to labs. Dr. Richie says some have also neglected the art of prescription writing and asserts that schools do not teach prescription writing with the detail as they did in the 1980s. Dr. Richie says DPMs are providing less information to the labs regarding specific patients, adding that some podiatrists submit blank prescription forms along with casts. Dr. Smith notes that more podiatrists are starting to use accommodations and customization for patients. However, he does acknowledge that some DPMs use uncomplicated rigid devices to control symptoms. He sees a slow but steady improvement in the quality of negative casts. Dr. Smith says that as practitioners learn proper joint positioning, the number of forefoot valgus casts increase while the number of forefoot varus casts decrease. He says DPMs are slowly mastering the ability to evert the forefoot on the rearfoot. Q: Since most major podiatric seminars today neglect topics on foot orthoses, how can DPMs continue to learn and improve their skills in podiatric biomechanics? A: To improve skills in biomechanics, all three panelists suggest attending the International Conference on Foot Biomechanics and Orthotic Therapy (PFOLA), which balances original research with clinical application. While some regional meetings include tracks on biomechanics, Dr. Richie says several national meetings have not focused specifically on biomechanics in several years. “This is a disturbing trend since lower extremity biomechanics and foot orthotic therapy was originally the one discipline which set us apart and gave us tremendous advantage over other foot and ankle clinicians,” asserts Dr. Richie. “The vast majority of DPMs in this country still rely on biomechanics and non-operative interventions on a daily basis. A few labs put on local workshops occasionally around the country but there is no single educational institution whom podiatrists can turn to for continuing education in the field of lower extremity biomechanics and foot orthotic therapy.” To remedy that, Dr. Smith says podiatrists should demand the inclusion of biomechanics in every seminar. Q: Do you perceive that the profession is still interested in learning more about podiatric biomechanics and foot orthotic therapy? What are the solutions to ensure that the profession does not lose its hold on the science of lower extremity biomechanics? Are we giving it away to other specialists like pedorthists and physical therapists? A: Dr. Scherer emphasizes the importance of podiatrists taking a leadership role in research in order to apply skills to patient care. Although podiatrists were first to apply the concept of lower extremity biomechanics to patients, he says professionals such as orthotists and physical therapists place more value on orthotic therapy. “Podiatrists started this ball rolling and we should be the experts,” says Dr. Scherer. “Being the expert doesn’t just mean telling people we are the experts. It means we must learn more, become the leader in finding new information, share our knowledge, and make sure the podiatrists that follow us are well informed and skilled at orthotic therapy.” Dr. Smith believes the profession does want more knowledge about orthotic therapy but says one obstacle is a lack of uniform knowledge. He suggests more scientific research and outcome studies to define the clinical applications of orthotic therapy. In addition, Dr. Smith advocates more classroom and clinical exposure for podiatric students, and also suggests the funding of a biomechanics fellowship. “We need talented, dedicated professors who can and will make a career of teaching this material,” says Dr. Smith. “Podiatry, alone and by itself, can lose its position of dominance in orthotic therapy if it (podiatry) chooses to ignore the science of biomechanics and its clinical applications,” continues Dr. Smith. “Unless the pedorthists and physical therapists make a concerted academic and clinical effort to understand and treat the foot, podiatry is in no imminent danger of losing its dominance in the field of orthotic therapy.” Even if DPMs lose interest in CFO therapy, Dr. Richie warns that a lack of understanding of biomechanics will significantly impair their surgical ability. “Unless we continue to combine the teaching of biomechanics with surgery, our profession will produce inadequately trained foot and ankle surgeons,” points out Dr. Richie. Dr. Richie is an Adjunct Associate Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt College. He is the Immediate Past President of the American Academy of Podiatric Sports Medicine. Dr. Scherer is the Chairperson of the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt College. He is also the CEO of ProLab Orthotics/USA. Dr. Smith is the Vice President of Northwest Podiatric Laboratory and is a Professor Emeritus at the California College of Podiatric Medicine at Samuel Merritt College.