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

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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