Managing Expectations In A Successful Foot Orthotic Program

Patient education and managing multiple expectations are crucial components in many aspects of the practice of medicine, and orthotic therapy is no exception. Here the panelists discuss their experiences with topics such as where orthotics fall in their overall treatment plans, how they manage expectations in different patient populations, pearls on patient education and what they do when patients aren’t happy with their orthotic devices.

Q: What are your established algorithms in terms of foot management in relation to orthotic implementation? Are there certain goals or benchmarks you address first (i.e. pain, deformity, etc.) before beginning orthotic therapy?

A:

Orlando Cedeno, Jr., DPM FACFAS, shares that in his practice, properly establishing a diagnosis and overall treatment plan is the most important aspect to establish before even considering an orthotic prescription.

Without a proper biomechanical examination, which is usually at the root of foot and ankle pathology, proper customization of the orthotic is unattainable,” he says.

Dr. Cedeno relates that his comprehensive pathway to treatment consists of:

• manual examination of the extremities, including evaluation of the lower

extremity nerves, joint range of motion, and points of pain on palpation;

• X-ray examination;

• gait examination;

• casting for orthotics as indicated; and

• pain control via holistic, medicinal, or immobilization methods.

Jenny Sanders, DPM agrees that the underlying biomechanics are key in many cases. She shares that since her practice primarily focuses on sports medicine, her first priority is healing a patient’s injury. If the injury is recurrent and non-traumatic, there is a good chance that a biomechanical etiology is the cause, she says.

“To determine an etiology, we do a complete biomechanical workup, including non-weight-bearing examination and Go 4-D dynamic force and pressure mat scans,” she says. “Utilizing this system, we are able to assess and compare both walking and running gait patterns. This informs us about limb symmetry and lower extremity pathology and helps us identify the best treatment approach.”

Olivia Stransky, DPM points out that she carefully considers when orthotics could be useful in a treatment plan.

“I love orthotics and let my patients know that, but I practice the concept of, ‘if it isn’t broken, don’t fix it,’” she says. “I see plenty of non-painful flat feet that that do not get an orthotic recommendation. I use orthotics to address pain. My goal is to educate the patient on gait abnormalities, physical therapy, anti-inflammatories, and orthotics to cure the problem (pain).

Generally speaking, Dr. Stransky sets the expectation of working on the acute pain during the process of orthotic fabrication, so the orthotics can help prevent recurrence of the inflammatory condition”

Q: How do you conduct patient education as it pertains to orthotics when dealing with an athlete, pediatric, geriatric, or weekend warrior population?

A:

Dr. Sanders uses data from her orthotic scanning system to provide education to patients, citing objective, graphical information including center of force trajectory, gait cycle pressure and force measurements and overall foot risk analysis

“This information, along with our “old school” biomechanical evaluation, clearly identifies the biomechanical factors we need to address,” she explains. “When patients see this, they immediately understand more about their biomechanical challenges. All patient demographics, including parents, athletes, and even geriatric patients appreciate this knowledge.”

Dr. Stransky focuses on creating realistic expectations for all patients. Specifically in the pediatric population, she says she generally avoids custom orthotics, as their feet grow so rapidly that she finds it may not be worth the investment of time, money, and materials.

“I recommend pre-fabricated, aggressive insoles in children with pathologic flat feet,” she elaborates. “I then council the patient and parent on switching to custom orthotics around the age of 16 once the child’s feet stop growing. We talk about wear and tear on ligaments, tendons, and joints which is why they may benefit from custom orthotics long-term.”

For athletes, Dr. Stransky shares that she addresses sport-specific topics, relevant athletic gear, and foot strike.

“After much reading and coaching, I personally don’t think it matters if a person heel strikes or midfoot strikes when running,” she says. “If my patient has a midfoot strike, I tell them to wear their orthotics every day, all day, except in running shoes. This is because the mechanics of an orthotic rely on balancing the rearfoot and the forefoot. If they heel strike, I advise they also use the insert while running.”

Depending on the specific activity, Dr. Cedeno says he addresses the patient’s goals and how they relate to motion, joints, and classic body regions of overuse. For instance, he points out that a baseball catcher’s orthotic will be different then a runner’s orthotic because the catcher’s target area of overuse is the knees. The other component to consider lies within the shoe gear needed for the sports, he adds.

Dr. Stransky agrees that shoe gear is a vital consideration, sharing that in her experience lacrosse and soccer shoes can usually accommodate an orthotic, so she provides her orthotic lab guidance on the intended sport shoe. For ballet dancers and rock climbers, she advises using orthotics anytime but during their sport.

She also shares that some individuals may have pre-conceived notions about orthotics that aren’t always correct, and that it is important to recognize when even the best educational efforts may not effect a change in their opinion.

Q: How do you try to set realistic expectations for patients with orthotics?

A:

Dr. Cedeno relates that he requests that patients keep a pain diary prior to beginning orthotic treatment and for two weeks after, reinforcing that a diminishing pain trend is a realistic goal.

Dr. Stransky asks patients to allow time to adjust to their orthotics, conveying a goal that at four weeks of consistent orthotic use, patients should be comfortable and experience about 50 percent pain relief.

“I let them know that orthotics are an art form, and to expect occasional necessary adjustments,” she shares. “Give me a few tries to adjust an orthotic. If it doesn’t work, I will accept a return and process a refund. Granted, I don’t offer the refund option on day one, but if I am three adjustments into a pair I do bring it up. This is a rare occurrence, though.”

Stressing the role of orthotics in the overall treatment plan is one way that Dr. Sanders manages patient expectations.

“Orthotics are only a part, albeit a large part, of improving biomechanical function and preventing further injury,”

she explains. “Also important are physical therapy, including strengthening and flexibility, as well as helping patients select the proper shoes. Unlike cortisone injections, which can have immediate effects noted, we inform patients that orthotic therapy can take longer, but can overwhelmingly provide long-term benefit and improvement.

Q: What are the most common complaints that you hear when patients are unhappy with their orthotics and how do you handle these complaints?

A:

Dr. Stransky finds that patients struggling with their orthotic treatment plan say that the devices don’t fit into their desired shoes, or they don’t want to wear the shoe required for the orthotic. She then reinforces the mechanical correction that shoes and orthotics create together to alleviate pain. It is important that patients realize that rarely is there a pill or shot that will cure their concern quickly and effectively.

Dr. Cedeno says there are a few common points of feedback that patients give when not happy with their orthotics. If the arch is too low or too high, he will revise the orthotic with a grinder or completely if necessary. Also, lack of relief (for instance, of plantar fascial pain) is a potential concern, which prompts him to examine the case further clinically, radiographically and biomechanically.

For runners specifically, Dr. Sanders says the most common complaint she receives is the development of arch blisters with extended runs, but not walks.

“This happens primarily with forefoot runners,” she says. “Fortunately, with 3D-printed orthotics, I can make the orthotic arch more flexible with a slight heat adjustment.”

Similar to Dr. Stransky, Dr. Sanders will make every effort to address patient concerns with their orthotics and will offer a refund if the issues are not resolvable. She agrees that this rarely necessary, however.

Q: Do you recommend a post-orthotic checkup visit as you would conduct postoperative visit for surgical intervention?

A:

All of the panelists carefully follow up with patients after dispensing orthotics. Dr. Cedeno meets with the patients after two weeks to determine satisfaction and discuss pain scoring. At the bare minimum he says he will arrange for a telehealth appointment.

Dr. Sanders regularly sees her patients with orthotics, starting at one month after dispensing, six months and then annually.

“The one month follow up is to make sure they are wearing the orthotics as prescribed. The six month follow up is to confirm realization of the desired biomechanical benefit. Lastly, the annual follow up is important to assess the orthotics for wear, including top covers, with replacement if necessary.

Dr. Stransky also sees orthotics patients one month after dispensing as she previously described.

Q: Do you as the podiatrist cast, mold, or scan your patients for orthotics or do you train staff to do so?

A:

Dr. Cedeno relates that he molds his own orthotic casts using Plaster of Paris. He says the only time he allows staff capture a mold using a foam box is for patients that need a diabetic accommodative insert and have no obvious pre-ulcerative lesions or osseous pathologies.

With proper training, the other panelists do commonly involve staff in the process of scanning for custom orthotics.

“We have a comprehensive training program to teach our medical assistants how to position a patient for 3-D laser foot scanning, as well as how to record a patient’s gait utilizing the dynamic mat scan,” says Dr. Sanders.

She goes on to say, however, that due to the knowledge and expertise necessary for the process, only the podiatrist will interpret the graphs and biomechanical gait information for prescribing in her practice.

Dr. Stransky, who also uses a 3D scanning system, says she has a few staff members trained to do execute the scan, and do it well.

“It is quick and easy to check a 3D scan, but redoing a plaster cast takes a lot more time,” she elaborates. “If a person has a very abnormal foot or area that needs offloading, I do the plaster casting.” n

Dr. Cedeno is a Fellow of the American College of Foot and Ankle Surgeons and is in practice in Jupiter, Florida.

Dr. Sanders is a Fellow of the American College of Podiatric Medicine and is in practice in San Francisco, California.

Dr. Stransky is a Fellow of the American College of Foot and Ankle Surgeons and is in practice in Denver and Conifer, Colorado.