02/16/2021    Keith L. Gurnick, DPM

Prescription Orthotics Pearls (Tom Silver, DPM)

Here are some of my ideas.
I believe this is a great subject so others should
feel welcome to respond.

1) Do not order one set of "compromised" custom
orthotics that will work in all varieties of shoe
styles for your patients. You will end up with an
orthotic that still doesn't fit in some shoes and
also doesn't function well enough in the shoes
they do fit into. On those patients who will
require different types of orthotics because they
wear different shoe styles, make one set for the
most important shoes and wait a bit and then make
other sets at a different date when you see how
your patient responds to the first ones.

2) Never, never, never make multiple sets of
orthotics at the same time when it is the
patient's first time using foot orthotics, even
when the patient tells you they want to purchase
multiple sets. Make and dispense the first set,
wait a couple weeks for the patient to see how
they respond, and if all goes well, then order for
the patient as many sets as they are willing to
purchase and pay for. This will save you time and
costs by not having to adjust or modify multiple
sets of problem orthotics.

3) Bulky orthotics do not fit well in shoes. Only
order modifications such as deep heel cups and
flanges and clips and thick padded coverings when
absolutely necessary and advise the patient that
this will require different shoes. Patients become
frustrated and angry when they learn they will
need to purchase new or different shoes, after
they come in to be fitted for the orthotics.
Advise the patient in advance, but try to
prescribe and order the least bulky orthotic that
will get the job done. And if the patient is
wearing bad or worn out shoes, advise them in
advance that orthotics work as a system in shoes.
They must have proper shoes for orthotics to work
well. I like the leaning tower of Pisa analogy:
The tower is made of white marble but the
foundation was built on unstable soil, etc.

4) Here is a good one, but you may need to fall
off the bike once or twice to become a believer:
When an elderly patient comes in who has old worn
out full length leather accommodative orthotics
and the patient wants/needs new orthotics, do not
try to change them to rigid or functional
orthotics, even if you think they need it. If
they were happy with their leather orthotics, do
your best to "newly" replace the inserts. If you
try to make them something more modern (carbon
fiber, poly plastics) you will likely lose the
battle and lose the war. If you want to win the
battle and avoid the war, make them a beautiful
nice new set of full length leather accommodative
devices and you will have a very happy patient.

5) If you expect insurance to be involved in
payment for orthotics, check benefits in advance,
know the benefits in advance and obtain coverage.
Always reference the call with a reference #, to
whom you spoke and the date and time. Create a
form and modify the form over time. When you are
told that orthotics are covered subject to
diagnosis, they usually will not be covered. Rule
#1: Always get deposits from your patients. It
is much better to issue a refund to the patient
when insurance pays, than to try to collect the
money later. I do not subscribe to the "Wimpy the
Hamburger Man" philosophy: Wimpy use to say, "I
will gladly pay you for next Tuesday for a
Hamburger today." When it comes to orthotics, if
a patient says they will pay you later, you know
that they can pay you now. If they will not pay
you now, they probably won't want to pay you
later.

If you want lots of orthotics sitting in your
office waiting to be picked up, don't get
deposits. If you want orthotics to be picked up
and into your patients’ shoes, get deposits.

Keith L. Gurnick, DPM, Los Angeles, CA

Other messages in this thread:

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02/18/2021    Joseph C. D’Amico, DPM

Prescription Orthotics Pearls (Tom Silver, DPM)

Here’s a few of my pearls that I don’t think have
been thus far been mentioned. It should go without
saying that unless there has been a thorough
biomechanical examination of at least the lower
extremity along with observational gait analysis
these suggestions of and by themselves are
incapable of effecting optimum alignment,
performance and symptom resolution.

1) Neutral subtalar position plaster impression
casting in the supine position. This position, as
recommended by Drs. Root, Weed, Orion, Blake,
Kirby, Valmassy, Smith, Scherer and countless
others allows a true representation of the
forefoot to rearfoot relationship and lessens the
likelihood of excessive varus being incorporated
into the impression due to gravitational forces as
is observed in the prone position.

This does not mean I never use the prone position
but reserve it for use in some children and those
individuals in whom I’d like to replicate the
total degree of forefoot varus I clinically
observed to be present. One additional note if
you’re going to err in the cast position err on
the slightly supinated side of neutral rather than
crossing over into a slightly pronated attitude.

2) Utilize an assistant to stabilize the leg at
the genicular level while performing a subtalar
neutral plaster impression cast in the supine
position. This allows the foot and ankle to be
positioned properly and if need be somewhat
forcibly without being influenced by any primarily
frontal plane movement of the leg occurring during
the casting process.

3) Make sure to capture the calcaneal inclination
region both medially and laterally in the cast by
constant smoothing and attention to this area
during the casting process. Sheldon Langer DPM
once asked me what’s the most important part of
the orthotic and I said the posting and he said no
it’s the calcaneal inclination region. Richard
Nuccio DPM former long-time instructor at NYCPM
also always stressed the importance of capturing
the medial calcaneal inclination area during the
casting procedure. This insured that the device
would exhibit maximal control especially critical
in the difficult to control golf ball like
calcaneal segment.

4) For optimal results paraphrasing the words of
Royal Whitman, MD - whenever there’s motion
available endeavor to correct rather than accept
the problem.

Joseph C. D’Amico, DPM, NY, NY

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02/15/2021    Steven E Tager, DPM

Prescription Orthotics Pearls (Tom Silver, DPM)

What I consider pearls are more likely than not a
way of practice life. Somewhere along the road a
bright light came on and a few things became more
apparent than ever. More “pearls” if you will:

• Rearfoot to lower leg alignment is an absolute
must if FF control is to be established. Hence the
need for a RF post most of the time.
• With the FF following the RF (for most of us
bipeds) it’s the bandleader. The FF (the band)
takes its cue and does whatever its told to do. RF
malfunction simply means FF malfunction i.e.:
functional adaptation. Neuromas, bunions, HT’s TB
HR, HL etc. etc., etc. results.
• Neutral position closed kinetic chain suspension
impressions technique is an absolute must. No fill
for sure as noted by Dr. Caringi.
• Without a thorough biomechanical exam (Dr.
Manolian) you’re flying blind in a snowstorm. The
more information available, the more intelligently
the treatment and results outcome improves.
• Perfect alignment is not a must. The body we
live in continues to be an amazing piece of
equipment. Get it close enough and it will adapt,
and symptoms subside.
• Shoe fit always a concern. Amazing how many have
no clue.
• Put an orthotic with motion control posts in
shoe with an unstable outsole and watch the whole
process fail. (check Mark Reeves, DPM Virginia
Mason Hospital) guidelines for shoes)
• Review Rich Blake’s book the Inverted Orthotic
Technique. Perhaps a better name for his book
might have been “Saving the Lower Extremity from
Unnecessary Surgery.
• Glasses are to eyes as orthotics are to feet,
except invisible.
• Functional adaptation doesn’t appear in the
morning.
• Resting calcaneal stance position (RCSP) is very
real and often clearly demonstrates the control
objective.

Enough said? Probably not! More response in kind
may be necessary. It’s the foundation of our
specialty. Help others to help themselves.

Steven E Tager, DPM, Scottsdale, AZ