Podiatrists prescribing surgical/orthopaedic footwear

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Hi

Can anyone tell me if they are involved in an NHS service that carries out Podiatry-led prescription of orthopaedic/surgical footwear???

We are drafting a proposal and need any info to help build the case!!

Lawrence

 

Hi Lawrence

I have lead a Footwear service at Durham since 1999. Happy to give any help I can. Either PM me or david.liddle@nhs.net
David

 

thanks very much!

 

I do paeds ones as part of an MDT.

 

Podiatrists doing roles outside their remit? Surely not!

 

Again a case of stick to what you are good at! Why have a halfway house service where you can only do stock or semi bespoke and if you cannot get it right you have to refer to someone who has the right tools for the job i.e. orthotists?

 

...or better still refer to or involve a Certified Pedorthist Custom Maker as part of your MDT, within your clinic that can make and or modify footwear for you

 

Lawrence, I think you are in the UK?

As far as I, as an orthotist, am concerned, it seems logical that podiatrists take some of the clinical load, particularly in the diabetic patient group. Continuity and lack of ambiguity about treatment plans are critical in providing quality patient service. The anatomy of the foot, understanding of biomechanics at the foot and ankle is better understood by podiatrists (if your profession is accurately represented by this forum)

I would, however, make some comment about the companies who are available for manufacture. Many foot orthosis manufacturing labs have a dedicated clinician who is knowledgable in both clinical application and manufacturing techniques. Most shoe manufacturers do not have this type of staff. They are predominantly technicians whose understanding of anatomy is limited. As such, the primary problem that I have encountered in podiatrists prescribing footwear is the gulf in terminology and knowledge base between clinicians and technicians.

Orthotics as a profession and orthopaedic footwear provision is no exact science. It's somewhat agricultural by comparison to the type of biomechanics discussions on here. It is still something of an artisan skill and patient expectation is the key factor for footwear provision. I can make the best fitting shoes that are unbelievably comfortable. If they look like an orthopaedic boot and all the connotations, they will sit in the back of a cupboard. That is why the diabetic group are sometimes easier - you tell them what they need and if they don't wear it, they are putting their lives at risk. Many choose to follow your advice unlike rheumatoid patients who are notoriously difficult to provide for.

Not sure if this helps your task but if I can offer any advice about companies to use and the cost vs quality argument let me know - send me a PM

Regards,

Robin

 

Well robin I have to disagree. Unfortunately I think this forum does not give a true picture of the standard of biomechanics knowledge that podiatrists in the uk have/are taught. I know from working with podiatrists on a daily basis that the knowledge base they gain from university is very small in comparison to other countries and a lot of the time they can 'talk the talk' but not 'walk the walk'! If all podiatrists had the knowledge of not just foot biomechanics but biomechanics of the whole body that some of them do on this forum then i would have no issues with podiatrists getting involved in footwear provision.

I disagree totally that podiatrists are best served for assessing biomechanics of the foot. I know from personal experience that orthotists are taught at university for up to 6 hrs a week for 3 years from experienced bioengineers on mechanics/biomechanics so I will let you decide who is best served for working in the field of biomechanics.

 

My remit is "the foot and its related structures". How is this outside my remit and who decided that it is?

 

And what knowledge do I have "Bamble1976"?

Please don't be too offended when I say I know from personal experience that not all Orthotists are as you describe. I would also say that you are not in a position to dictate to Podiatrists what they do, just as I am not able to dictate to you.

 

Well I don't know about all of you, but it's very much jumping to conclusions to assume or even suggest that presciption footwear could possibly be outisde out remit. It's essential to it. I would request that before people make these accusations that they know what (and who) they're talking about first.

Admittedly I was trained in Australia and not the UK, and so have a strong biomechanical background. It has always been part of my job and training to prescribe surgical footwear, wherever I have practised UK and AUS, and I've been doing it my whole career. As I am the most experienced all the trickiest patients are sent to me in my MDT for prescription footwear. I also have access to a paediatric orthotist too as I need to use them, and I do if I think I could do with their opinion/input. I am suprised that there is even any suggestion that this is outside our remit. I always work closely with the shoe makers and respect their advice or input for clinical matters I am at all unsure how to persue. We have an excellent working relationship together, not in competition

At my first graduate job (in Australia), the Podiatry Department had the sole prescribing rights to the orthopaedic footwear budget (and not the Prosthetist/Orthotists) for the whole state, as elected by the Orthopaedics Department as the orthopods felt we were best for the job. Perhaps my training and experience is not typical?

 

Well, do you think a four year podiatry degree with double those weeky contact hours, focussed solely on lower limb suggests perhaps I do know a little about the biomechanics of the lower limb (plus one or two other things)?

You can't slate an entire profession before you really know what you're talking about. Keep it nice.

 

As a podiatrist who does prescribe footwear, I can only emphasise Robin's comments.
Even though I work for a company that makes bespoke footwear, I still found it extremely difficult to do the job.
I believe a significant amount of experience is required and this only comes with practice.
The MOST important thing is to get a good working relationship with the technician who is going to make the footwear and definitely pay them a visit at their place of work - ideally with a job you would like them to make.

Again from personal experience I found the 'prescriptive' part of the shoe design - either bespoke or to the patients own footwear - for example rocker soles etc, to be fairly easy to understand and only a little help was required in tweaking my design.
However the measuring,material choices and last work options available was tough to manage.
Best advice is start with modular footwear if upper changes are required or patients own footwear if sole unit only Rx are required.
After that move onto bespoke.

Cheers

Phil

 

It is worth bearing in mind that there are vast differences in the training of orthotists too the world over. NZ, Aus and South African trained orthotists are fantastic in my experience of working with loads of them the world over. The rest can be hit and miss. IMHO

 

Thanks for you help guys - I will be in touch!

The title of this thread may have inflamed some passions but the content of my opening post was for "Podiatry-led" footwear services. This does not mean to say "Podiatry exclusive".

The modern NHS is using professions like Podiatry far more to manage cases that would have gone to Orthopaedics - to save cost. With £20 billion to save in the next 5 years this will only increase. When you add in the diabetics, rheumatoids and elderly that go through Podiatry it makes sense to me that Podiatry leads the footwear provision.

In this scenario, following assessment and treatment planning, a patient needing shoes would hopefuly see those whom would serve their needs best be it a local retailer or Podiatrist or it could be concluded that a patient may be best served by an Orthotist. It would make sense if that Orthotist were a directly employed NHS staff member rather than external contractor as this would facilitate much easier dialogue, multi-discplinary working and accountability than is often the case but thats another story.

I think from the points raised so far we can conclude that footwear provision is a difficult job that requires specialised skilled personnel. It may well be that providing patients with stock and modular shoes is a skill set below that of provision of bespoke - the issue then becomes what percentage of the caseload require bespoke. We can also conclude that both Podiatrists and Orthotists possess these skills, whether they actually do or not is down to local issues.

 

You may be right in that Podiatry Arena is not an accurate representation of the general biomechanical knowledge in the UK of podiatrists. In that respect, as you concede, you would have no issue with podiatrists getting involved with footwear provision if the level of biomechanical knowledge was as is represented here and I would agree.

As a former training officer for orthotic students in their 6 month placement, I tried to ensure that I gave as much biomechanical knowledge as possible. But, I have to say that having spent (paraphrasing)3 years at university being taught up to 6hrs per week by bioengineers about biomechanics, their general level of knowledge on foot ankle anatomy was depressingly poor, let alone how biomechanics affects that anatomy. That is why I can say that podiatrists are perhaps every bit as capable of prescribing footwear as orthotists.

Having graduated from University and starting a job in 2000, I had prescribed 2 pairs of modular footwear and only measured for 1 pair of bespoke shoes which were only done to a fit stage(and that was in the first year of my Uni education, 3 years before I actually had to start measuring on patients) before being let loose on patients. In my opinion, this makes me no more experienced than someone who has never ordered a pair of shoes before.

Another element of this equation is that there are not much more than 600 orthotists. We are spread pretty thin, usually with excessive case loads and poor waiting lists. Is farming out some of the less complex stuff to other professionals who you consider inferior not a better usage of your time, if it allows you to do what only you can possibly do?

What are you afraid of? That you are going to become obselete as a professional? We should be embracing each others abilities and trying to learn from one another. I have learned more from this forum in 9 months than I learned in 8 years of being a clinician. In that respect I can make the decision that orthotists do not have exclusive rights to biomechanical knowledge

Just a word of advice, this is probably not the best forum to say that podiatrists can "talk the talk" and not "walk the walk". Lack of respect for podiatrists will not improve the general feelings about orthotists(if indeed you are an orthotist, I sort of made that assumption) I'm not saying that you have to agree with me and my opinion but Lawrence put it nicely

Sincerely,

Robin

 

I am indeed an orthotist. As I said sally I am stating that the level of training for podiatry in the uk is nowhere near that of countries like australia. The many number of podiatry students I have in clinic stating that their basic knowledge gained in biomechanics from university is very poor unlike that for diabetes, rheumatology etc which is of a very high standard.

My issue is that if the basic level of not just LL biomechanics but biomechanics of the body as a whole is so poor, then for it to be the norm that podiatrists start to prescribe footwear as well, then this is what bothers me when orthotists are in a position to do this already.

I think their needs to be a general standard of biomechanics taught at university far higher than it is now, somewhere near what craig payne is doing at latrobe. If this was the case then I would have no issues with cross training for allied health professionals. I have the greatest respect for people like craig, kevin, simon who have a great knowledge of biomechanics. Perhaps it will take someone from another country like craig to come over and share what they are teaching!

I think that this is a great forum for sharing new ideas but also lets us (uk) understand that there is a vast divide in teachings therefore it is not a level playing field!

Robin - I am surprised that you had so little footwear experience at uni as i completed about 20 pairs at the end of my 6 month placement.

 

Indeed.

Cui bono ?

 

Are you asking me or is it rhetorical - sorry, i didn't quite follow

Robin

 

We are all learning, developing and trying not to be obselete.

Cui bono? or "who profits?" is an interesting way of understanding human nature.

 

This is a very interesting topic for me !
If the biomechanical knowledge are reflected in the "prescription form" of foot orthoses I assume that a "prescription form" it is necessary to exist for surgical/orhopaedic footwear too. There are a lot of models for foot orthoses prescription forms but I don't know such a prescription form for footwear! Do you know a model of footwear prescription form where the biomechanical knowledge to be transposed in technical parameters ?

Daniel

 

Lawrence

there are several VERY GOOD podiatry depoartments areound the Uk fitting surgical bespoke and stock footwear.
a good contact is Jayne Mcadam in Salford (hope hospital) the pods fit ALL the footwear in the area with excellent results.

Salford Uni run Shoe fitting courses for Pods as does Staffs Uni.

also other areas fitting footwear -Mile End hospital London all footwear is Pod fitted

South West wales the same -Lorna Greer is the contact there.

Hope this helps

 

Your remit isn't the application of exoskeletal supports to "the foot and its related structures". This skill requires not just Biomechanics but also mechanics, hence a 4 year degree which combines these 2 sciences.

I have had correspondence from your own profession who will happily concede - this is not their remit in fact they won't go near it as not qualified to do so.

 

Mark

I think your negative experiences with pods and footwear may be justified or just unlucky. However I don't think this is down to ability but more to do with practice.
Footwear is about simple Newtonian mechanics that most people can understand and apply.
I have found footwear prescribing to be challenging but DEFINITELY within my scope of practice.
If you want to be confrontational and compare training, I would ask you to look at the quality of our training in tissue viability, endocrinology etc.
Footwear is part of the clinical needs of patients we are skilled at treating so well within our remitt.

Phil

 

The only prescription form for footwear that l know of in Australia is on for returned soldiers (DVA).
The form is simple.
Shoe history, what they have had in the past.
Clinic history, e.g ulcer location, diabetic, HAV.....
Modifications required ( for depth or existing shoes)
Special features, might ask for velcro..and thats about it.

The client is then refer on to us (Pedorthist) we then take our own history, assessment and cast/measurements. at this point no biomachanical information is passed on from the refer.

When the podiatrist or orthortist check any shoe they look for fit and function, if they find anything they dont like, they may write us a note to have changes made, its a team effort

l dont quite understand what they are arguing about, whether it is writing out this type of form or making the footwear?

l know of no Orthotist or Podiatrist that make footwear here in Australia, they refer them to the like of me or in some cases l do an in house service at their Clinic, the greater number dont do shoe modifications either, these are also refer on.

 

Mark,

Let us not forget that 50% of the 4 year degree course that qualifies one to be an orthotist is spent doing prosthetics (possibly more than 50%).

As David says,

The question is, who is best placed to deliver a service that provides footwear to a clinical population which for example could be ulcerative diabetics?

To answer, I think about practicalities.

What is the ratio of podiatrists to orthotists in a given hospital? 3 to 1 perhaps. Where I work, it is 8 to 1.

Who is best placed to offer continuity of care in the case of treating an ulcerated foot? Is the person treating the ulcer not best placed to make the judgement as to when measure of footwear should take place with an idea of timing until the affected tissue becomes viable.

How many orthotists have the clinical capacity to slot diabetic patients into clinics on a daily basis for a quick footwear measure. I'm not saying that podiatrists have oodles of spare time on their hands, but again, their ability(because of the frequency of seeing a patient)to anticipate when someone requires footwear means that scheduling it in would be easier, I would have thought.

Which profession, on the whole, has better knowledge about diabetes and its effect on the feet?

What percentage of orthotic services are provided by private contractors who have it written into their contract that only their goods and their orthotist can be used. Is this always the best for the patient?

When I answer these questions, I cannot help but think that surely podiatrists have a place in prescribing orthopaedic footwear. I also don't think that the study of mechanics in the form of upper limb orthotics, spinal orthotics and Knee Ankle Foot Orthoses has any great relevance to footwear prescription. Admittedely, material science may he considered relelvant. I would be interested to know what percentage of the 4 year degree course for orthotics (and prosthetics) was actually footwear and foot biomechanics related.

I'm not saying that podiatry does more, I just don't think it does that much less. I also think that teaching from the 2 schools of Prosthetics and Orthotics is not very uniform and graduating to be an orthotist in Scotland is quite different to graduating to become an orthotist in England so standards vary greatly in the same way that podiatric standards vary which I think is one of the point Phil was making.

Regards,

Robin

 

Please define exoskeletal support and tell me who said I cant apply one?
Is a shoe a exoskeleton support? Shoes are not part of my remit at all?
You'll be trying to tell me I cant apply a bandage next. I suppose OT's and Physios can't do wrist splints?
How do biomechanics and mechanics differ?
Who makes the Medical/Podiatric diagnosis for the appliances any technician measures and fits for?

Get over yourself.