Challenging Conventional Thinking On Orthotic Therapy And Podiatric Biomechanics

Every now and then, I catch an episode of Bravo’s Inside The Actor’s Studio. At the end of the hour, the interviewee participates in a pithy, amusing and sometimes revealing questionnaire. One of the standard questions is “What is your least favorite word?” For me, it would be two words: conventional and assumption. Those who assume are too lazy to seek out the truth. Conventional implies there is one predominant way of doing things but the dynamic nature of our lives suggests different models. Interestingly enough, a number of articles in this month’s issue offer challenges to the perception of conventional wisdom or the prevailing thinking on orthotic therapy and podiatric biomechanics. For example, the panelists for the Orthotics Q&A column (see page 32) raise a number of provocative challenges. For example, Bruce Williams, DPM, the column’s Guest Clinical Editor, challenges the notion that accommodative soft devices are best when it comes to offloading for those with diabetic plantar ulcerations. If practitioners do not address the poor, asymmetrical foot function in this patient population, Dr. Williams says they will be fighting a “losing battle” to offload the ulcer and improve overall foot function. While Chris Nester, BSc, PhD, says he was taught that the foot controls the lower limb, he has found in his clinical experience that is not the case. A Senior Research Fellow at the Centre for Rehabilitation and Human Performance at the University of Salford in the United Kingdom, Dr. Nester says the foot can influence proximal limb structures but would not be a primary influence over the knee and hip. Accordingly, Dr. Nester says the foot “is just one of a number of interdependent structures we need to consider” when it comes to lower limb mechanics. In another provocative view, Craig Payne, DPM, says motion and foot position are not necessarily associated with pathology. Dr. Payne, a Professor in the Department of Podiatry in the School of Human Biosciences at Latrobe University in Melbourne, Australia, adds that changes in foot posture and motion with orthoses are not necessarily associated with positive results. Paul Scherer, DPM, who is a proponent of pathology specific custom orthoses, offers a closer look at emerging studies on the use of orthotics in patients with rheumatoid arthritis (see page 58). Citing one recent review of studies in this area, Dr. Scherer says the authors found “strong evidence that foot orthoses do reduce pain and improve functional ability.” Dr. Scherer takes the insights from these studies and formulates a practical guide on the goals of custom orthotic therapy for RA patients with foot pain and limitation of activity. In the cover story, Patrick DeHeer, DPM, a team podiatrist for the Indiana Pacers and the Indiana Fever, cites a recent study that highlights the preventive value of custom orthoses in college basketball players (see page 38). He also shares a number of practical pearls from his experience in treating basketball players over the years. For example, Dr. DeHeer notes that most elite basketball players have a low tolerance for rigid orthotics and prefer softer, more accommodative devices. He concedes that many biomechanical experts will disagree with this but maintains “those who have been involved with professional or collegiate basketball players for any substantial amount of time know this to be true.” In reading these articles, one can see the use of orthotic therapy may require less conventional assumption and more of a dynamic approach, an approach that combines insights from emerging research and one’s clinical experience to facilitate improved outcomes for patients.