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

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    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