Current Insights On Functional Foot Orthotics And Choosing A Lab

Our expert panelists discuss the role of functional foot orthotics in their practices, their approach to patients referred to them for custom orthoses, keys to selecting orthotic labs and whether healthcare changes will have an effect on the perception of orthotic outcomes.

Q:

How do you currently position functional foot orthotic therapy in your office?

A:

Functional foot orthoses play a big role in the practice of Kevin Kirby, DPM, who notes he receives patient referrals for custom foot orthosis therapy from podiatrists, primary care physicians, physical therapists and chiropractors within a 100-mile radius of his office. He also receives referrals on a regular basis from local running shoe stores for patients who need custom orthoses. Approximately 25 percent of the custom orthoses Dr. Kirby makes are for recreational athletes, 25 percent are for work-related foot and lower extremity injuries, and 50 percent are for non-athletic patients who have a wide variety of mechanically-based foot and lower extremity pathologies.

Karen Langone, DPM, says her practice is known primarily for its work in biomechanics and most of her patients get referrals due to multiple musculoskeletal injuries and pathologies. Many present for orthotic evaluation upon referral from other practitioners after having pursued and completed other therapy plans. Generally, with those types of patients, Dr. Langone will consult with the patient initially and address any treatment options such as functional assessment and physical therapy specific to the particular issue that have not been explored by previous clinicians. She will also evaluate shoe gear, order any additional studies as needed and possibly order an OTC device if it is indicated. One would evaluate the patient’s response to the temporary device at a later appointment. Dr. Langone says one can then modify this device, implement an alternative treatment plan if desired or prescribe custom functional orthoses.

Dr. Langone will also perform a biomechanical examination and video gait analysis. The results will then determine if functional orthotic therapy is necessary and she proceeds from there. While there are no definitive rules, she says approximately 90 percent of these referred patients will require a functional device.

Paul Langer, DPM, uses functional foot orthotics as well as OTC insoles as significant treatment modalities for the foot and ankle conditions that he sees daily. There are several factors he uses to determine whether he needs to go to a custom device or OTC device. Dr. Langer questions if a temporary device will suffice, whether the patient had any type of insole/orthotic previously or if he is treating a chronic or new injury. If the patient has a cavus foot or a pes planus foot, then he knows OTC devices will be less effective and/or comfortable.

“Given that ‘prescribing’ orthotics is not as simple as prescribing, for example, antibiotics, my preference is to start with OTC devices or insole modifications prior to casting for a custom orthotic,” says Dr. Langer. “Since humans do not respond in systematic ways to biomechanical interventions, I like to learn about how they might respond by starting with a device that I can change and modify until I can confirm that the patient finds it comfortable and it addresses the pain/pathology.”

Once he is confident that the patient has responded favorably, Dr. Langer will then present the option of casting for a custom orthotic.

For patients who initially present to Dr. Langone and have not sought treatment elsewhere, she will generally attempt conservative methods (injections, physical therapy, stretching, shoe recommendations, modification of activities, etc.) prior to functional orthotic therapy. However, Dr. Langone will move more quickly to orthotic therapy if the pathology is extremely severe, if there are multiple complaints, if there is a contributory medical history, if the patient is looking to return to activity as soon as possible, or if the patient is a competitive athlete looking to maximize performance. She always incorporates quality physical therapy in her treatment plan.

Q:

What were your top three reasons for choosing your current lab? What would you tell new practitioners to consider?

A:

Dr. Langer says consistent quality should figure into the decision on which lab to use. He says one should be confident that the lab will consistently follow the prescription and use quality materials to make the devices.

Similarly, Dr. Kirby emphasizes the importance of the quality of the lab’s product. He advises asking the following questions: Are the prescription variables correctly ordered into each orthosis? How many options for different orthosis plate materials and topcovers does the lab offer? Does the lab offer medial and lateral heel skive orthosis modifications? Does the lab automatically make symmetrical orthoses by scanning only one cast instead of scanning both casts as it should? Only after considering these factors, should the podiatrist consider the price of the orthosis since, as he notes, without good quality orthoses, orthotic outcomes will suffer.

Dr. Langone would tell new practitioners to consider a lab’s product quality, turnaround time and customer service.

“We are looking to provide the absolute best orthotic available to our patients,” notes Dr. Langone. “We respect that no lab is perfect (and certainly neither are we), but the response of an orthotic lab to any problems that arise is essential to successful orthotic therapy.”

Communication is also important for Dr. Langer. He stresses the lab must be available for calls or e-mails to address questions the physician may have, and also be proactive about calling if the lab has questions or concerns regarding a cast or prescription.

Dr. Langer also likes a lab that will keep up with research/technology. He asks if the lab representative can speak intelligently about additive manufacturing (3D printing) and orthotics, and discuss the pros and cons of casting methods including laser scanning versus plaster casts. Dr. Langer also considers if the lab regularly updates its materials or is at least able to discuss the different shell and topcover materials that may be available.

Q:

Do you believe the importance of orthotic outcomes has changed along with our changing healthcare?

A:

As Dr. Langone notes, many patients now have large deductibles, coinsurance and additional charges of every imaginable kind imposed by insurance companies, ensuring patients now carry a larger financial burden for healthcare. However, Dr. Langone notes patients will pay for services when they understand the importance and benefits of these services.

“We must provide pain relief and improved quality of life for the patients that purchase our services,” asserts Dr. Langone. “We must provide value and benefit for our patients’ healthcare dollars. This is key to a successful practice.”  

In contrast, Dr. Langer believes the importance of outcomes is unaffected by healthcare changes. He cites great evidence in the research about the effectiveness of orthoses for lower extremity pain and injuries.

“Those who are skilled and educated know that a key to good outcomes in orthotic therapy is to make the best device that is customized to the patient’s pathology and biomechanical profile, and then make sure to work with that patient after dispensing if the desired outcome is not achieved,” says Dr. Langer. “An ethical practitioner would do that whether the insurer is paying for the device or the patient is paying out of pocket.”

In Dr. Kirby’s practice, the importance of good outcomes with custom foot therapy has increased over the years. More podiatrists are sending their patients to brace shops for custom foot orthoses and he notes this typically results in substandard orthoses. Dr. Kirby sees a large number of patients who get referrals solely due to his reputation for making quality custom foot orthoses for patients.

“Podiatrists who are not skilled at custom foot orthosis therapy are, unfortunately for themselves and their patients, missing out on one of the most important therapeutic modalities for their patients who have mechanically-based foot and lower extremity pain,” says Dr. Kirby.

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. Langer is in private practice at Twin Cities Orthopedics in Minneapolis. He is an Adjunct Clinical Professor at the University of Minnesota Medical School and a board member of the American Academy of Podiatric Sports Medicine.

Dr. Langone is a Fellow of the American College of Foot and Ankle Orthopedics and Medicine, and the Treasurer of the American Association for Women Podiatrists. She is a Fellow and Past President of the American Academy of Podiatric Sports Medicine. She is in private practice in Southampton, NY.

Dr. Mitchell is a Fellow of the American Academy of Podiatric Sports Medicine and is board certified by the American Board of Podiatric Medicine. She is in private practice with Mercy Medical Group, Inc. in Sacramento, Calif.