08/22/2015    Stephen Peslar, BSc, DCh

Are We Still

In the commentary written by Dr. Shavelson,
the article that he links to is disturbing for
three reasons.

First, the author mentions that a CPed or CO
spends hundreds (?) of hours studying foot
anatomy, biomechanics & related pathologies but
the author does not mention that current board
certified DPMs do an undergrad bachelor's degree,
4 years of study at a podiatry school and then a
3 year residency.

The second reason is that podiatry students did
manufacture their own orthoses for patients back
in 1983. We used Rhoadur back then and
unfortunately it cracked quite often. When I took
a course at CCPM back in 1987, a prof there said
his preferred choice was Rhoadur because of the
level of control he was able to obtain from it. I
assume podiatry students today still manufacture
orthoses (both accommodative & corrective) from
newer and better materials than Rhoadur.

The third reason is the most disturbing because
the article was written in British Columbia,
Canada. In BC, podiatrists are registered &
licensed to practice by the College of Podiatric
Surgeons. Does the public there feel comfortable
going to a podiatric surgeon for orthotics? When
was the last time you referred a patient to an
orthopaedic surgeon for an AFO? Furthermore,
since the podiatrists in BC seem to focus on
podiatric surgery, Footcare Nurses of Greater
Vancouver Association has formed. See
http://footcarenurses.ca the home page states,

"We are a group of Independent Footcare Nurses,
from the Greater Vancouver Area and throughout
British Columbia..." Also, "Standard foot care
treatment protocol involves the care of the foot
and nails, including mobility [does this include
orthotic/AFO assessment, casting and
dispensing?], health assessment and physical
trimming of nails, reducing calluses and
thickened nails including client teaching."

From the Services/Prices page, "Prices for home
visits range from $35-$45 per person per visit
and additional fees [for orthotics/AFOs?] may be
charged in special circumstances."

The questions that come to mind are, have the
podiatrists in BC practice only foot surgery and
therefore call themselves podiatric surgeons? Has
this opened the door for CPeds & COs to be the
primary foot orthoses providers for the residents
in BC? Also since podiatric surgeons seem to
mainly practise foot surgery, has this enabled
independent footcare nurses to provide
conservative foot care? Finally, is this
phenomenon concurrent in other jurisdictions in
Canada & the USA.

Stephen Peslar, BSc, DCh, Toronto, Ontario

Other messages in this thread:

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09/01/2015    Stephen Peslar, BSc, DCh

Are We Still "Kings" of Orthotics? (Elliot Udell, DPM)

I have been reading the opinions from
podiatrists and to date, no podiatrist has
discussed the insurance companies' strategy to
maximize profits by reducing payouts for
prescribed medical appliances. This is why Dr.
Udell is incorrect when he wrote insurance
companies, "want to see current, well-written
research papers." These companies only want to
see profits and they do this by reducing
payouts.

I remember 25 years ago, perusing patients'
insurance benefits booklets and the benefits
covered: prescription orthotics, $400;
orthpaedic shoes, $400; braces, $400; trusses,
$400; prescription eye glasses, $400. Today,
some insurance companies pay $100 for
prescription orthotics, $400 for custom made
orthopaedic shoes and $100 for prescription eye
glasses per calendar year. Why? Locally, in
Toronto, I've seen podiatrists, chiropractors,
physiotherapists and even massage therapists
cast and dispense orthotics.

We've all seen the growth of LensCrafters and
other fashion boutique eyeglass optician
dispensers. I was perturbed when I saw patients
spending $500 each year for eyeglasses when
they got $400 per year coverage for them but
they used the same orthotics for 5+ years even
when the top cover came off.

Well today, due to over prescribing, many
insurance companies are providing $100 for
orthotics and $100 for eyeglasses. Also there
is only $400 coverage for custom hand made
orthopaedic shoes. Locally, they cost $1,500+
per pair and the patients wearing them can't
wear extra depth nice looking "orthopaedic"
shoes with custom made orthotics.

How many studies prove the effectiveness of
eyeglasses? How many of us depend on
eyeglasses? I see patients who can't walk 10'
without orthopaedic shoes. Despite this,
insurance companies keep the payouts low and
unfortunately will not increase them even if
there are 100 scientific, well-researched
studies that prove the effectiveness of custom
made orthotics.

Stephen Peslar, BSc, DCh, Toronto, Ontario

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08/31/2015    Don Peacock DPM, MS

Are We Still "Kings" of Orthotics? (Elliot Udell, DPM)

All of Dr. Udell's comments are correct and his
philosophical stance toward the purveyors of
theoretical concepts is a cause for us to have
natural skeptical attitudes. Science and art
definitely coexist in the field of medicine and
to a great degree in the implementation of
orthotic design. Where I disagree with Dr. Udell
is the notion that this intermingling is a bad
thing. Of course, differing concepts and opinions
will surface and that's completely natural.

The theoretical prophets all make up their
theories and they do this through the creative
imagination. These artist/scientist are a gift to
us. I find it fascinating when someone challenges
an accepted dogma despite its ingrained
followers. Wrobel has an interesting conclusion.

Some may read this conclusion to mean that a
custom orthotic is no better than an off the
shelf. It could also mean that the way we make
orthotics needs improving, etc. Also, it could
mean that certain foot types respond and some do
not et etc. Similar research has shown the
ineffectiveness of NSAIDs, injections, physical
medicine, surgery chronic plantar fasciitis.

The most interesting research for me in this area
that fractures the concept that the fascial band
is inflamed. Dr. Harvey Lemont showed in
histological studies that the plantar fascial
band is not inflamed. Is the name plantar
fasciopathy more appropriate?

Recently, Dr. Stephen Barrett has given us a way
to stage plantar fasciopathy via ultrasound and
its relation to fascial band thickness in the 3
known zones. If you want a better knowledge of
when conservative care is likely to work look at
this concept of staging. If you want a
biomechanics theory that you can put to the test
and get great results try Dennis Shavelson's foot
typing.

We are the Kings and we are still in need of a
tutor. All I know is I have a lot to learn.

Don Peacock DPM, MS, Whiteville, NC

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08/31/2015    Stephen Albert, DPM

Are We Still "Kings" of Orthotics? (Elliot Udell, DPM)

Reading PM News exchanges from Drs. Richie,
Udell, Kesselman, and Phillips, I am compelled to
join them as President of the American College of
Foot and Ankle Orthopedics and Medicine (ACFAOM).
I wish to do so in a broader context rather than
just Dr. Wrobel’s article. By the way, James
Wrobel, an acquaintance of mine, is an excellent
podiatric researcher.

ACFAOM believes that biomechanics and medicine
are the cornerstones of contemporary podiatric
practice. With that in mind I wish to underscore
the educational avenues available to
practitioners and those still in training
available from not only ACFAOM but other sources
as well and also address a couple of other issues
mentioned before.

Acknowledging the comments of Drs. Richie,
Kesselman and Phillips and using Dr Udell’s
comments as a segue, I will comment upon the 3
areas underlined below.

“Up until now, education in biomechanics has
been, by and large, in the domain of self-
declared experts. They occupy bully pulpits at
conventions where they espouse their own theories
of how an orthotic should be made and why it
works. The obvious problem is that if you attend
five lectures by five different individuals on
this topic, you will hear five different sets of
conflicting theories and recommendations. This is
because the information given by these speakers
has not stood up to the scrutiny of solid
university-based research.”

1) Regarding education in biomechanics, perhaps
some readers are not aware that ACFAOM offers
yearly educational conferences. We pride
ourselves in offering conferences that are case
based, evidence based and interactive. Our last
Annual Conference was in conjunction with the
APMA National in Orlando and our next is
scheduled to be in Savannah, GA June 24-26, 2016.

Admittedly, I have a bias, but the lecturers over
last few years have been presenting a more
consistent EBM view on biomechanics. And Drs.
Richie, Philips among others have presented in
the past. A video sampling of the recent Orlando
conference will soon be available at the ACFAOM
website.

2) ACFAOM also has on its website a Live Learning
Center (acfaom.org) featuring biomechanics
education. Both videos and text with an expert
opinion of how to properly bill for your
biomechanical exam. Also not to be missed is the
reference and link to “The 4 Peer-Reviewed
Journal Articles Every Podiatrist Should Read.”
This article points to the importance of
biomechanics to conditions podiatrist encounter
every day in their practices.

3) ACFAOM also offers a booklet on Prescription
Custom Foot Orthoses Practice Guidelines

4) And lastly we offer a Review Text in Podiatric
Orthopedics & Primary Podiatric Medicine,
currently under revision to reflect the latest in
EBM.

I should mention that outside of ACFAOM

1) There is no arguing that more research in
biomechanics and foot orthoses is needed by
podiatrists. Yet we must not ignore other sources
outside of our profession for today that is where
much of the “solid university-based research” is
found.
Presentations at the International Foot and Ankle
Biomechanics Community (iFAB.org) meetings
include solid university-based research. They are
an international group admittedly not all
clinically oriented nor DPM’s for that matter.
North American meetings occur periodically
interspersed with international ones.

2) A website I suspect rarely frequented by the
surgically-focused DPM is Podiatry Arena
(podiatry-arena.com). Hosted by podiatrists,
down-under, in Australia. It has a forum for all
podiatrists worldwide. If you are a “self-
declared biomechanics expert” and post to the
forum you will be challenged to prove your
“expertise” with evidence.

I wish to credit podiatry-arena.org for the
following graphic comparing The Scientific method
vs. Faith-based Methodology in biomechanics.

3) Recently, two biomechanics book reviews
appeared in The Journal of the American Podiatric
Medical Association May 2015 issue. Drs. Spooner
and Shapiro provide excellent reviews and
acknowledge the engineering principles and tissue
stress concepts that are underpinnings of our
current biomechanical knowledge of foot and lower
limb function. Each book provides numerous
references to current biomechanical research.
For full disclosure and a disclaimer, I played a
co-editor role in one of the books.

Perhaps my comments have shed some light as to
the available resources for those interested in
foot and ankle biomechanics in a broader sense
than just custom vs. pre-fab foot orthoses. And
by the way, that was a topic at a recent ACFAOM
conference.

In conclusion, I will repeat, not only does
ACFAOM believe that biomechanics and medicine are
the cornerstones of contemporary podiatric
practice we view our role primarily as educators
in biomechanics and podiatric medicine.

Stephen Albert, DPM, President, ACFAOM

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08/28/2015    Robert D. Phillips, DPM

Are We Still "Kings" of Orthotics? (Doug Richie, DPM, Elliot Udell, DPM)

I note the never-ending debate on the value of
pre-fabricated orthotics vs. custom-made
orthotics, with everyone holding dear to their
position by citing their favorite research
article. This is indeed a most superficial debate
and shows failure of those who engage in it to
dig down into basic biomechanics and basic
mechanical science. If anyone who really studies
these basic sciences uses a term such as “moment
of inertia” or “stress-strain curve”, or even
“direction cosines” we find a vast majority of
clinicians who shut the mental blinders,
believing that they don’t need to understand math
or physics – after all they are “real surgeons.”

While I could make a whole lecture on the subject
of why pre-fab orthotics work or don’t work, I
would like to make just a few points in this
correspondence.

1. When we prescribe a custom made orthotic, what
are we really selling? A piece of plastic or
leather to go into our shoe? I would maintain
that what we should be selling is expertise. If
we don’t take any measurements, if we don’t do
muscle testing, or gait analysis, and we let
nurses take our impressions, and we don’t do
careful follow-up and have the ability to make
small changes in our offices, then what are we
really selling? I notice an interesting statement
in the PM News from the other day, ““You can’t
manage what you can’t measure.”

2. If we dig down just a little into the basic
science, the simple fact is that if an orthotic
is contacting that foot when it is in its “ideal
position” [I’m not going to get into what that
position should be] then it may be able resist
deformation of the foot from that ideal position.
The less the orthotic deforms from that ideal
shape when the body weight is placed on it, the
less the foot will deform from the ideal
position. I see people at trade shows pick up an
orthotic, try to bend it with their hands, and
decide whether the orthotic is too rigid. Such is
fallacy as I know no one that can bend an
orthotic with their hands with the same force a
foot will try to bend it with body weight. Such
a person may want to test the effectiveness of
their car springs by putting a 20 pound bag of
sugar on the springs.

3. Many pre-fab orthotics have a 3D contour that
is close to an individual’s ideal foot shape
contour. With the wide variety of pre-fabs on
the market, it is possible to find among the
myriads, at least one that has a contour that
fits any specific foot. Therefore it doesn’t
matter if the form is prefabbed or custom made,
it has to have the right contour.

Custom-made is usually a much easier and faster
process than sorting through the numerous pre-fab
devices to find the right one. One particular
prominent orthotic laboratory has a large library
that he can fit a great majority of foot shapes.
Such a library bridges the pre-fab and true-
custom made market. None of the studies that
have compared pre-fab and custom made orthotics
have given us any data as to how close the shape
of the pre-fab is to the shape of the custom-made
orthotic.

4. You do not need to have “full control” of foot
motions to alleviate plantar fasciitis. You just
need to relieve the tension of the tissues enough
to get them out of the plastic region, into the
elastic region of the stress-strain curve. I am
very surprised that Dr. Udell has to use so many
additional anti-inflammatory measures in addition
to the orthotics. It would be of great interest
to study the practice techniques and orthotic
techniques of those who have low percentage of
patients responding to only orthotic therapy
versus those who have a high percentage. This is
the true Evidence Based Medicine Study that needs
to be done.

Robert D. Phillips, DPM, Orlando, FL

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08/28/2015    Paul Kesselman, DPM

Are We Still "Kings" of Orthotics? (Doug Richie, DPM, Elliot Udell, DPM)

I have read the paper referenced by my two
esteemed colleagues as well as their comments.
This is in fact an excellent start for evidence-
based medicine (EBM) papers which podiatry
desperately needs. When my colleagues meet with
insurance executives the paucity of these types
of papers are often the most obvious hurdles we
have to overcome to convince medical directors
that orthotics are worth paying for (or continue)
to pay for.

Say what we want how custom foot orthotics save
money by avoiding costly surgery and post-
operative complications, they want to see
peer review studies proving our contentions. So
while the flaws and positive outcomes of this
study have been pointed out by Drs. Richie and
Udell, no study is perfect. And has also been
pointed out, this is an excellent start, but more
papers like this are needed, especially those by
podiatric authors.

Some of my colleagues may be correct in their
opinions where they would rather see custom
fabricated orthotics (CFO) not covered at all;
with decreasing or very limited reimbursements
for them, I can't say they are entirely
incorrect. However, this study could be the start
of a trend where reimbursement strategies for CFO
change. Also, since many patients simply cannot
afford them nor do the pre-fabricated types of
devices work for them, this may allow those set
of patients access to CFO.

Regardless of which side of the fence you are on
with respect to reimbursements from third-party
payers, the podiatry profession needs more EBM
papers on the efficacy of CFO and many of the
other treatments we regularly advocate. Thanks to
Drs. Richie and Udell for a job well done in
bringing this attention to those of us who
regularly have to negotiate these issues with
insurance carriers.

Paul Kesselman, DPM, Woodside, NY