Current Insights In Prescribing, Replacing And Refurbishing Orthotics
These expert panelists discuss when to make new orthoses, when to refurbish them, when to make a second pair and what role footwear plays in the prescription.
How does footwear affect your decision process when prescribing orthotic devices?
The goal when prescribing orthotic devices is for the patient to be able to wear them as much of the time as possible, according to David Levine, DPM, CPed.
“However, it is impossible to make one pair of orthotic devices fit all shoes perfectly,” says Dr. Levine. “That’s why it is essential to either make the devices for the shoes worn most of the time or the ones that the patient is wearing that cause most symptoms.”
Gregory Smith, DPM, asserts that it is easier to adapt orthotics to current footwear than it is to get patients to adapt to new footwear.
When prescribing a sport orthotic, Lee Firestone, DPM, prefers to fabricate a full-length orthotic to replace the existing insole in the shoe.
Kevin Murray, DPM, will typically start out making an orthotic for the patient’s athletic shoes. While treating a patient for an acute problem, he will try to get the patient into an athletic shoe or a shoe that can accommodate a full length orthotic. If the device is for a patient who does not exercise and spends most of his or her time in a flat or dress shoe, he will make the orthotic for that shoe.
Dr. Firestone says men’s dress shoes with removable insoles should also get a full-length orthotic and he encourages men to wear dress shoes that work with full-length orthotics.
Fabricating orthotics for women’s dress shoes can be a challenge, notes Dr. Firestone. He only recommends fabricating custom orthotics for women’s dress shoes if the heel height is 1½ inches or lower. Generally, he chooses a ¾-length orthotic with a thinner shell material such as graphite. Dr. Firestone prefers sandals with removable foot beds and will send the sandals to the lab for a custom orthotic.
As Dr. Levine notes, there are situations in which discussing shoe selection is even more important than the fabrication of orthotic devices. For the best orthotic outcomes, he says starting at the ground and working up will produce the best success. Dr. Levine emphasizes that an integral part of the overall treatment plan is educating patients regarding appropriate footwear and guiding them to the shoes that will function the best with the orthotic devices.
When and/or how do you recommend additional pairs of orthotic devices for the same patient?
If it is the patient’s first experience with orthotics, Dr. Firestone customarily starts with one pair of orthotics and chooses a device that is more versatile for the patient’s needs, whether it is for dress shoes or athletic shoes.
“We all know that some orthotics can take a tweak or two to get them right,” notes Dr. Firestone. “Patient satisfaction comes first.”
Once Dr. Firestone and Dr. Levine see the patient is benefiting from the orthotics and have made all adjustments, they will consider a second or third pair. Dr. Firestone encourages runners and triathletes to use additional pairs of orthoses because it is important to let the shoes and orthotics air out after long runs and hot days. Since a dress orthotic does not always work with a sport shoe and vice versa, he tells patients it is a good idea to have both a dress and sports pair of orthotics. Dr. Firestone’s practice will offer a discount to the patient when he or she orders more than one pair.
Dr. Levine will fabricate the second pair for other shoes so the patient’s feet are supported as much of the time as possible. Sometimes he notes the lab can make two pairs right away but says it is often best to make sure the first pair is as close to perfect as possible before making a second pair.
If patients are happy with the results of the orthotics but cannot get them into all shoes, Dr. Murray lets them know he can make a second pair to fit in whatever shoe they wish.
Dr. Smith asks patients about activities and the kinds of shoes they wear. “If they run for play and dress for success, then I would offer a sports orthotic and dress orthotic,” notes Dr. Smith.
How do you decide to refurbish or make new orthotic devices?
Dr. Firestone generally recommends new orthotics if the orthotic is more than seven years old or there have been significant structural changes to the foot since the fabrication of the last pair. The choice of shell material also influences his decision. He notes harder shell orthotics such as polypropylene and graphite retain their shape, and are easier for labs to refurbish while softer shells such as polyethylene or subortholene may lose their shape and can be a challenge for the lab to refurbish. If the patient does not want to part with the orthotics during the refurbishment, Dr. Firestone recommends fabricating a duplicate pair of orthotics. After getting the duplicate pair made, he will send the old pair out for refurbishment.
Dr. Murray and Dr. Smith recommend new devices if the orthotics are old and symptoms have returned. If the plate still fits the foot shape and is not excessively worn, as one can ascertain by performing the countertop compression test, Dr. Smith will refurbish the devices. Dr. Levine concurs that if symptoms return, the best solution can be making new orthoses. If the devices are old but there has been no return of symptoms, Dr. Murray will recommend refurbishing the current orthotics.
Often, Dr. Levine says re-covering or reposting can make the devices like new. Alternately, if it has been awhile since the current orthoses were made, he will make a new pair and then refurbish the old pair. Depending upon the type of orthotic device made, Dr. Levine says orthoses can last anywhere from two years or more.
Dr. Firestone is in private practice at Foot and Ankle Specialists of the Mid-Atlantic in the Washington, DC area. He is board-certified in foot surgery by the American Board of Foot and Ankle Surgery.
Dr. Levine is in private practice at Foot and Ankle Specialists of the Mid-Atlantic in Frederick, Md. He is also the director and owner of Physician’s Footwear, an accredited pedorthic facility, in Frederick, Md., and the owner of New Balance-Frederick.
Dr. Murray is in private practice at Blue Ridge Foot and Ankle Clinic in Charlottesville, Va. He is board-certified in foot surgery by the American Board of Foot and Ankle Surgery.
Dr. Smith is in private practice at Foot and Ankle Specialists of the Mid-Atlantic in Hagerstown, Md. He is a Diplomate of the American Board of Foot and Ankle Surgery, and a member of the American Society of Podiatric Surgeons.