Expert Insights on Load Management & Orthotics

In a new Podiatry Today podcast, Dr. Nick Romansky discusses the concept of load management, and how applying it to orthotic plans can impact outcomes.

Q: What does load management mean when it comes to orthotics?

A: Orthotics play a very big role in load management, where you are trying to load, unload, accommodate, and control to a point, the forces going through the foot and lower extremity.

Five times your body weight goes through the foot every day.¹ Seventy percent goes through the first ray.² If you run, then it’s typically 5 to 7 times your body weight every time your heel strikes.³ Those numbers may vary, but over time, those joints, those bones, the knee, and the low back, take a beating.

Hopefully load management is a term and a concept that clinicians can incorporate into their practices.
 
Q: How can DPMs approach load management in their orthotics programs?

A: I think with any patient, you need to look, you need to listen, you need to feel, and you need to examine the patient and really see what their needs are, specifically for their sports participation, their foot type, and their systemic problems, such as diabetes. This is especially true for a patient with diabetes, where you’re trying to unload the fifth metatarsal base or the heel that had an ulcer.

In my experience, you don’t really need a force plate or a force mat to look at pressure distribution. You don’t need to be in a lab at an academic institution to do this. Just by looking at the patient, listening to the patient, and examining the patient, you see a callus or you see not much fat pad in the heel or the ball of the foot—you can lose that over time or in the patient with diabetes. So just by seeing that and listening to the patient, and then coordinating that with their shoe type and their needs, that all plays into the foot management and load management to make the appropriate orthotic.

Again, the critical thing with any orthotic is how this device fits in the shoe and the interface of the foot to the orthotic to the shoe. I think a lot of orthotics fail because of improper fit in the shoe. That’s why I like to send the shoe or tracing where you have the appropriate interface that your device seats itself directly in the cleat, the turf shoe, the hiking shoe, or the typical running shoe.

Q: Are there any specific features of the biomechanical or physical exam that can provide clues to how clinicians can best address load management?

A: Again, where is the load? Where is the patient feeling it? Where are you seeing it? A lot of times when it comes to load management, some of the things I consider are a deeper heel cup, more padding on the forefoot, a metatarsal pad or a metatarsal bar, different materials that help shock and shear. Sometimes I will taper the front of the orthotic device so it fits better in a pickleball shoe versus a typical running shoe that has a higher toe box. Sometimes I’ll change the posting.

Again, this is where sometimes talking to your representative, your service consultant, or rep at the lab can help you. When they look at the cast in front of them in the shoe you send them, and then you have a conversation, ultimately you have less chance of failure and you both collaborate on that device.

I think one of the things that we have lost focus on as far as fabrication of orthotics is limb length discrepancy versus functional limb length discrepancy. Is the discrepancy truly structural? Truly that one set of bones on one side is actually, truly longer or shorter versus something that’s functional, which is muscle weakness, compensation, and muscle imbalance.

How do we evaluate that before a custom fabrication? You get an X-ray or computed tomography (CT) scan, and you know that if you have to put an accommodative heel lift on or a heel sole wedge on, that orthotic will make up for the structural change that may be causing a problem such as fasciitis, heel strike pain, shin splints, low back issues, because the patient truly has one leg longer than the other, structurally.

So again, you have to look at the patient’s foot connected to the rest of the body and where that device can be fine-tuned to unload certain areas and balance out areas.

Again, it’s an orthotic. It’s not an arch support that you can get over-the-counter that just literally brings the ground up to you.
 
Dr. Romansky is fellowship trained and a Diplomate of the American Board of Foot and Ankle Surgery. He is a team podiatrist for the U.S. Men’s and Women’s national and World Cup soccer teams and is a design consultant for multiple shoe gear companies. Dr. Romansky is a medical consultant to many of Philadelphia’s professional sports teams and is a podiatrist to the Major League Baseball Empires Union.

References

1.    Brockett CL, Chapman GJ. Biomechanics of the ankle. Orthop Trauma. 2016 Jun;30(3):232-238. Doi: 10.1016/j.mporth.2016.04.015. PMID: 27594929; PMCID: PMC4994968.
2.    Patel J, Swords M. Hallux Rigidus. [Updated 2023 Nov 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556019/
3.    Birnbaum S. Force on a runner’s foot.