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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
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