Orthotics Q&A: Load Management

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Jennifer Spector, DPM: Welcome back again, everyone, to Podiatry Today podcasts, where we bring you the latest in foot and ankle medicine and surgery from leaders in the field. Our returning guest today is Dr. Nick Romansky, who's chatting with us this time about load management in orthotics in this special Orthotics Q&A episode. Dr. Romansky is fellowship trained and a diplomate of the American Board of Foot and Ankle Surgery. He's 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. He's a medical consultant to many of Philadelphia's professional sports team and is a podiatrist to the Major League Baseball Empires Union.
 
Dr. Romansky, thanks for joining us again, this time to talk a little bit about load management. Can you tell us what that term means when it comes to orthotics?
 
Nick Romansky, DPM: So load management is really probably a hot word that you hear now in the press, on the radio, in sports. Whether athletes are taking time off for load management, you mainly see mainly in the NBA, a little bit Major League Baseball, sometimes football, but basically it's just like really what it really sounds like, load management. So depending on who you read, either or with to five times your body weight goes through that foot every day. Seventy percent goes through the first ray. If you run, then it's typically five to seven times your body weight every time your heel strikes. Those numbers may vary, but over time, those joints, those bones, knee and low back, take a beating.
 
And so how do we want to try to minimize and distribute the load going through the lower extremity, including the low back, in my opinion, and the whole closed chain and open chain, if you want to get into true biomechanics and academics, but I kind of want to stay more in the clinical focus here.
 
So orthotics play a very big role in load management, where you really are you trying to load, unload, accommodate, control to a point, the forces going through the foot and lower extremity.  
 
Jennifer Spector, DPM: So how can DPMs approach load management in their orthotics programs?
 
Nick Romansky, DPM: I think again, mentioned previously, I think with any patient, you need to look, you need to listen and then feel, last examine the patient and really see what their needs are specifically for their sports participation, their foot type, their systemic problems, such as diabetes. I don't want to just focus on the need for orthotics with sports because it can be used in preop, postop, conservative care, sports participation, amputation, where you really comes down to really load management and, you know, especially in a diabetic where you're trying to unload the fifth metatarsal base or the heel that had an ulcer.

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. I mean, just by looking at the patient, listening to the patient, examining the patient, you see a callus or you see not much fat pad on the foot in the heel or the ball of the foot where you can lose that over time or in the diabetic. 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 is with any orthotic is how this device fits in the shoe and the interface of the foot to the orthotic to the shoe. And that's really, I think a lot of failure orthotics is because improper fit in the shoe. That's why I like to send the shoe or tracing where you have the appropriate interface that it actually sits down there and your device seats itself directly in the whatever maybe the cleat, the turf shoe, the hiking shoe or the typical running shoe.
 
Jennifer Spector, DPM: So are there any specific features of the biomechanical or physical exam that can provide clues to how clinicians can best address load management?
 
Nick Romansky, DPM: So again, where is the load? Where is the patient feeling it? Where are you seeing it? Okay, so a lot of times when it comes to load management, some of the things I consider is a deeper heel cup, a 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.
 
So again, you're looking at the materials, you're looking at what their needs are. 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 their cast, look at the cast in front of them in the shoe you send them, and then you have a conversation that ultimately you have less chance of failure and you both collaborate on that device.
 
But there's so many things to choose from when you're looking at that. And again, it's just not one device fits all. And again, you may have two different feet. I think one of the things that have really lost a lot when fabrication of orthotics is limb length discrepancy, true, strong. versus functional limb length discrepancy. Truly if they're short, the right's shorter than the left, the tibia versus the femur on either side. Is it 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.
 
And how do we evaluate that before a custom fabrication? You get an X-ray or CT scanogram, which most insurance companies will cover, that you know that if you have to put an accommodative heel lift on or a heel sole wedge on, that orthotic will make up the structural change that's now seen that may be causing a problem of fasciitis, heel strike pain, shin splints, low back issues, because they truly have one leg longer than the other, structurally.
 
Jennifer Spector, DPM: Is there anything else on this topic that you'd like to add for the audience today?
 
Nick Romansky, DPM: Yeah, I think when making the device which helps with load management as well in the biomechanical exam is again it's critical that you look at the shoe that this device is going to fit into. And so again with a different types of mesh toe box that are out there for functional reasons or cosmetic reasons that's when you may have to taper the front part of the orthotics so it fits in this, is not too much cramping of those toes and then they're going to get blisters and hot spots and nail injuries.
 
So that's really the one of the things is really look at the shoe and again a lot of times sending that shoe Then the person at the lab can look at that and say you know what maybe you made that forefoot extension (inaudible) maybe we should taper that or extend that. So again it's not just based on a foot that you got to look at their knees. And look at their foot connected to the rest of the body and where that does device can be fine tuned to load 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. Well, hopefully this is a term and a concept that clinicians can incorporate into their practices.
 
We'd like to thank you, of course, for sharing your insights with us today and the audience for joining us for this episode. This episode, along with previous and future ones, can be found on podiatrytoday.com, SoundCloud, Spotify, Apple Podcasts, and all of your favorite podcast platforms. Dr. Romansky is passionate about answering your questions on this topic as well, so if you have any specific questions for him, you can reach out to podiatrytoday and we'll get you in contact.