Welcome to the Podiatry Arena forums

You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members, upload content, view attachments, receive a weekly email update of new discussions, access other special features. Registered users do not get displayed the advertisements in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!

  1. Everything that you are ever going to want to know about running shoes: Running Shoes Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
  2. Have you considered the Critical Thinking and Skeptical Boot Camp, for taking it to the next level? See here for more.
    Dismiss Notice
  3. Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
Dismiss Notice
Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
Dismiss Notice
Have you liked us on Facebook to get our updates? Please do. Click here for our Facebook page.
Dismiss Notice
Do you get the weekly newsletter that Podiatry Arena sends out to update everybody? If not, click here to organise this.

Ethics in Orthotic Prescribing

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Mark Russell, May 1, 2006.


  1. Members do not see these Ads. Sign Up.
    The debate this weekend on Rothbart’s Insoles has demonstrated once again how valuable a resource Podiatry Arena has become for the global profession – not only for the ability to discuss and dissect controversial issues quickly and effectively, but for the diverse range of topics such a debate creates supplementary to the primary subject – the Bojsen-Mollor high gear/low gear thread being just one. Another, touched on late in the debate, is that surrounding the ethics of prescribing and the competency of the practitioner in Bx practice.

    As usual, Kevin asked some fairly searching questions of me in respect of my experience in orthotic provision for my patients – the quantity of devices I supply on a monthly basis and my opinions on the difference between prefabricated and custom-made devices. It may come as a surprise to some to learn that I supply very few, if any, laboratory manufactured custom devices, nor do I supply any prefabricated ones either. Partly this is because I have worked predominately within the NHS where the main focus on clinical delivery has been with the care of the elderly – and as such the demand for functional devices is limited – even contraindicated – for many of the cases we see.

    However, that is not to say foot dynamics and biomechanics do not underpin much of the clinical work in gerontology. Clearly, for most aspects of clinical podiatry, a thorough understanding of mechanical function is essential for good outcomes – from pressure relief in wound care; to weight redistribution in rheumatology; and tissue mechanics in common skin disorders - like plantar callous formation or HDs. Biomechanics, in the broadest term of the word, is central to most things that we do.

    But to say that gerontology-based general practice prevents me from incorporating functional devices into some treatment plans would be disingenuous – there are cases where prescription devices are indicated for elderly patients – however, I question my own competency in this area and for that reason I tend to refer to trusted colleagues as and when these cases arise. That is not to say I don’t have a reasonable working knowledge of lower limb biomechanics or that I cannot undertake a thorough and competent examination and make an appropriate diagnosis. I’m even fairly comfortable with current terminology although there are times I despair just how much additions there are to absorb and understand in this field (BM high gear/low gear, being a prime example). Perhaps, as Felicity has pointed out, this is simply because podiatry is a fast-developing profession and as our understanding of lower-limb conditions develops – so do the theoretical and practical terminologies. For an aging brain, however, it is becoming increasingly complex and hard work!

    However, my feelings of incompetence – if that is the appropriate term – lie not in my inadequacy of knowledge, but in my doubts about the effectiveness of the devices and the changes they have on the prevailing conditions. The revelation by Craig, that clinical outcomes between custom-made and prefabricated devices were equal came as a bit of a shock – but not a surprise. In nearly a quarter of a century of practice I have seen some frighteningly complex foot disorders that have attracted just as complex orthosis designs, which, in many cases, have failed to make a positive impact on the underlying pathology or the presenting symptoms and in some instances, have made the condition worse. Often, these cases respond better to simple chair-side insoles - especially in the aging foot where arthritic changes may well inhibit correction of the underlying bony structures. ‘Do No Harm’ is a maxim we would all do well to remember at times.

    Not least because there are so many variables to consider – the quality of the examination, cast technique, manufacturing process, material construction, patient compliance, mobilisation and supporting exercises - that often I think we should thinking in terms of quantum rather than applied mechanics when considering the effects orthotic therapy has on the patient..

    All of which has made me think a little on the ethics surrounding Bx practice in podiatry. Many of the concerns expressed over the weekend relate to the damage that can be caused by incorrectly prescribed or theoretically flawed devices - yet it seems to me that immense damage can be inflicted on our professional reputation by current practice, insofar as there is still a ‘trial and error’ approach adopted by many within the profession. We have strict controls on local analgesia and podiatric surgery – and for good reason – but there is currently no monitoring or mandatory CME/CPD for practitioners who prescribe devices that have the potential to cause immense damage to patient health.

    Is this an area we need to address?

    Mark Russell
    Last edited by a moderator: May 1, 2006
  2. Mark,
    If you look at cases of malpractice and litigation in the UK, by far and away the biggest source is the use of caustics, principally pyrogallol. I think this needs to be addressed first.

    In terms of biomechanics and orthoses, perhaps none of us really know and understand fully, but some of know and understand more than others.
  3. Simon

    Litigation is only one aspect of this. Professional reputation - especially amongst peers in the medical community - is founded and developed in many other areas - clinical effectiveness being prime. Fully accept what you say about knowledge, but for every Simon Spooner, there are a few hundred Joe Bloggs with similar professional recognition, supplying devices without any knowledge base at all.

    My point is should there be any controls - formally or informally? Did Rx Labs not insist at one time on some form of course participation prior to being accepted as a prescribing practitioner?
  4. javier

    javier Senior Member

    Hello Mark,

    I depends on the podiatrist (as health professional) to keep update their own knowledge. I do not know how Podiatry works in UK, but in Spain it is not mandatory to accomplish certain number of continuing education credits for keeping your license (like in US). Of course, we can discuss about the quality from CME course, but at least, there is some obligation for keeping updated.

    On the other hand, your primary source for knowledge about foot biophysics (not only biomechanics), foot conditions, foot orthotics prescription and, why not, orthotic manufacturing should be during university. When you get a Podiatry degree you are (at least suposed) to perform foot conditions diagnosis and treatments. Of course, there will be always better podiatrists (like every profession) than others.

    Finally, about your concern for potential harmful from foot orthotics, I can say (from my own experience), after dispensing hundreds of foot orthotics, that when an orthotic does not work it usually ends at the end of a drawer where little harm can do. That is the difference between conservative to surgical treatments, patient can choose to follow or dismiss the treatment.
  5. Craig Payne

    Craig Payne Moderator

    There have many complaints to The state Podiatry Association's ethics committees in Australia over the years from disatisfied patients about foot orthotic therapy (I see no reason for it to be different any where else). As a result the Australasian Podiatry Council developed the "Clinical Guidelines for Orthotic Therapy provided by Podiatrists" in May 1998 (ie a bit dated now and in need of some updating). We use these as part of the competency guidelines for students in our teaching clinic. The guidelines make explicit the process and outcome pathways expected during prescription, issue and review of foot orthoses.

    The way I see it, is that if a Podiatrist can demonstrate that they have complied with the guidelines (ie accurate clincial records documenting it) and there is a complaint (or worse, litigation), then they have a defence.
    Last edited by a moderator: May 1, 2006
  6. javier

    javier Senior Member

    In Spain, like all EU countries, foot orthotics (custom, pre-custom and OTC) are regulated by EU Directive 93/42/EEC of 14 June 1993 and every country own regulations. Directive 93/42/EEC also regulates prescription (but not assessment), manufacturing, documentation and guarantees. For instance, foot orthotics have a guarantee period for 2 years.

    But, these regulations do not cover topics such as ethic or professional updating (these matters are included in other regulations by professional bodies).

    Are there any cases of litigation involving foot orthotics prescribed by podiatrists for harmful effects?
  7. Cameron

    Cameron Well-Known Member


    Foot orthoses are not the preserve of podiatrists (arguably they should be?) and most people treat themselves with off the peg devices without the professions' knowledge. So it is impossible to draw hard and fast conclusions relating to the general population, based on the narrow exposure we pods have and the almost complete absence of quality checks on outcome in our practice.

    Podiatrist do not have a code of ethics (nor swear to uphold same) and so the best we can do is have a code of practice, As Craig rightly pointed out in Australia there is a Guideline (which is not mandatory), but represents acceptable practice which could be used legally as an example of a professional expectancy in the practice of podiatric orthotic care. However the document (in my humble opinion) ignores entirely the larger community responsible for orthotic prescription and is a prescriptive document (based on no clincial evidence and follows the appliance curriculum common in centres of podiatric education about two decades ago) and much less helpful than would appear. But it is a start. One abuse of the guidelines is some employers use it as a job specification where employees will follow through the prescribed stages as a matter of policy and not exercise clinical judgement. The implication being everyone will end up with a custom made device with contracts of employment drawn up to this effect. I can only suppose this was not the intension of the authors when they were formulated the guidelines but these are open to this type pf abuse . By contrast the Australian Podiatry Counsel guidelines for diabetes (a sister publication) is excellent and I believe this to be so because they were compiled within a multdiscipline setting and based on evidence based practice. My point is guidelines can be a help and a hindrence.

    My elementary understanding of bone physiology is the ability to realign joint surfaces in response to changing function diminishes with age and by the third decade this compensation cannot be taken as a natural function. If functional foot orthoses change the direction of ground reactive force through joint surfaces then there is an expectation the joint will physiologically adjust by laying down new bone. In the absence of this wearing functional foot orthoses could have the serious potential to cause traumatic arthritis. Often asymptomatic the indivdiual is left then to rely on the external support otherwise they suffer discomfort. Foot orthoses for older people could become habit forming under these circumstances. Practioners may well think they have provided the appropriate foot care never realising they have contributed to the presenting pathology. Accommodative management of the older foot carries less risk and the vast majority of foot orthoses dispensed to elders classified as geriatrics are made from semi compressible materials.

    Sadly we have bastardised the term "functional", as in functional foot orthoses which now means all things to all people but in its purest sense "functional" describes absolute control, which is not possible with frontal plane wedging. No mater the posting materials, the foot continues to pronate over the foot orthoses in the shoe.

    Caring for older feet is a specialist area and working within safe margins probably favours chiropody practice. Frail ambulent have greater potential to fall which Hilton has written extensively about and one of the biggest challenges is not orthotics but shoes.

    What say you?

    Hey what do I know
  8. javier

    javier Senior Member

    In Spain, we have deontological and ethics codes published by all podiatry professional bodies through the country such as http://www.colegiopodologosandalucia.org/mos_web/index.php?option=content&task=view&id=4&Itemid=30 (sorry in Spanish) and Ethics is part from the Spanish Degree Curriculum: "Professional Ethics and Legislation" http://www.uax.es/Internacionales/ects/ingles/POD.htm.

    Although, you are right about the lack of a code of ethics published for Podiatry, just check the website http://ethics.iit.edu/codes/health.html. Why? :confused:
  9. javier

    javier Senior Member


    What criteria do you use for clasificate a patient as geriatric? Age? My father is 70 and I discourage anyone to call him "geriatric"; Presence of Rheumatic diseases? It can be present in people below 50 years; Sedentarism and lack of activity? Unfortunatly it affects every kind of people indepently from age.

    From my point of view, foot orthotics treat foot conditions. Orthotics materials and design have to choosen based on therapeutic goals not age.

    I do not agree about the dicotomy functional vs. accomodative. Orthotics accomplish a function: relieve foot symptoms. You can achieve the same results using soft materials or rigid materials. Is there any consistent data that a 40 Sh Eva is better than a carbon fiber composite or the contrary? Materials can be choosen for giving a better comfort (EVA) or for keeping its shape during more time (polypropylene).

    Also, it seems that the concept "control" for foot orthotics is outdated. We should think in terms of moments not position. It was difficult to change my mind but it helps more to explain foot function and treatment achievement or failure.

    Of course, therapeutic goals will be different from an old lady living on retired home than a young athlete. It is a matter of common sense or not?
  10. Cameron

    Cameron Well-Known Member


    >What criteria do you use for clasificate a patient as geriatric?

    Geriatric is from the Greek "geron" meaning "old man" + "iatreia" meaning "the treatment of disease.". So I would classify geriatic as a disease associated with aging. The defintion varies with population and ethnicity but premature aging would also be classified as geriatric.

    >Age? My father is 70 and I discourage anyone to call him "geriatric";

    I would agree but geriatric is a term often associated with people over 65.

    >From my point of view, foot orthotics treat foot conditions. Orthotics materials and design have to choosen based on therapeutic goals not age.

    Choice of foot orthoses is goverend by material properties and their modulus of bulk, compression and elasticity will previal. As ground reactive forces are passed through the medium of the material this will physically determine what benficial effects (or otherwise) wearing the device would have. Certainly customising choice and crafting prescription will improve the outcome. Albeit as Mark has reminded us (via Craig's comments) that the evidence shows there is no difference between bespoke and off the peg foot orthoses.

    > I do not agree about the dicotomy functional vs. accomodative.

    We are in agreement there too. I classify foot orthoses by material. However the meaning of words may become important. "Function" in the numemclature of bioengineering, means something specific ie measured and accurate control.

    > Orthotics accomplish a function: relieve foot symptoms.

    This is a colloquial use of the term function and because I am using the term in a technical sense (and you are using it a ceveryday sense) we are not talking about the same things.

    Reasearchers running random controlled trials comparing hard and soft orthoses on people who can no longer can physiologically realign their joints, would be unlikely to get ethical approval and hence as far as I am aware there are no published trials. For that reason I would be very cautious about claims hard orthoses prescritions are ideal for physiological challenged joints.

    >Also, it seems that the concept "control" for foot orthotics is outdated. We should think in terms of moments not position.

    I agree. UInder these circumstances the Root orthoses would become an arch support after heel off, acting as a resupinator in conjunction with the Windlas Action.

    >It was difficult to change my mind but it helps more to explain foot function and treatment achievement or failure.

    No argument from me here either.

    >Of course, therapeutic goals will be different from an old lady living on retired home than a young athlete. It is a matter of common sense or not?

    Absolutely and again I would repeat the importance of chiropody and podiatry in the approach to careing for the older foot

  11. Admin2

    Admin2 Administrator Staff Member

  12. javier

    javier Senior Member

    I am please we arrive to agreement so quickly (other members should take account of this ;) )

    But, it is difficult to talk about ethics if podiatry (at least in some contries) lacks a code of ethics. How is it possible? :confused:
  13. Craig Payne

    Craig Payne Moderator

    Ethics and orthotic prescribing

    Finally got a moment to come back...

    What is orthotic prescribing?
    It is the matching up of particular characteristics of the foot and the environment to design parameters in a foot orthoses.

    How do you determine the characteristics and environment? - that where the H & P comes in (the P including a biomechanical assessment that looks for particular characteristics that need addressing by particular design features of the foot orthoses). Ethical issues here include having the clinical experience and competence to carry out the assesments that are indicated to make that decision. The 'landscape' here is constantly changing as new evidence becomes available, new concpets are being placed out there and evidence is displacing older concepts.

    What are the orthotic design parameters - these are too numerous to go into, but are you familiar with the cast modification parameters (ie heel pitch; heel expansion; arch contour; rearfoot wedging; medial/lateral skives; lateral coumn support; forefoot wedging; sweet spots; extended heels); the shell modification parameters (ie thickness; flexibility; anterior edge length; extrinic and instrinsic posting; forefoot width; heel raise; first ray cut outs; arch width; arch reinforcement; non-beveled front edge; heel post flare; low bulk grind; heel seat depth; cobra designs; aperatures; gait plates; first ray flexibility) and top cover modifications (ie fabric; material; thickness; length; metatarsal dome; pre-load the hallux; morthons extension; reverse morton's extension' accomodations; forefoot varus/valgus extensions; metatarsal bar; high medial overlay; posterior gluing). Are you familiar with indications and contraindications of all these? Are you being ethical if you do not have these at your disposal?

    Those that have heard me lecture over the last year or so, know that I do my best not to distinguish between custom made and pre-fabricated orthotics - they are all foot orthotics; they all have different design parameters that need to be matched to the characteristics and envirnoment of the foot --- many of the above design parameters can be provided by prefabricated foot orthoses and many can only be provided by custom made foot orthoses. Good clinical practice (ie being ethical) is having them all at your disposal.

    The evidence, is that in RCT's there is generally no difference in outcomes between custom made and prefabricated (to add to the published studies, there is Karls Landorf's soon to be publsihed RCT comparing custom made to prefabricated in plantar fasciitis - no differences found; I have also just heard on the grapevine about another big RCT that early data on custom made vs prefabricated in patellofemoral pain found no differences -- but I have no details that I can share)

    To me ethical practice is having the knowledge and skill to determine the characteristics and environment of the foot and match it up to the needed parameters. Who cares if its prefabricated or custom made?

    I often "rack the brains" as to when is a custom made should be prefered over a premade (and vice versa), and I have no defintive list, but here is the start:
    1) Some design parameters are only available in a custom made device
    2) Custom made device can generally fit better in the shoe (though some brands of prefabs are good as well)
    3) Custom made are less expensive (who agrees with this one :eek: )
    4) A longer lasting device is needed (though Karl's study showed Formthotics still as effective as custom made at 12 months)

    Prefabricated devices are probably indicated when:
    1) A short term devices is needed
    2) The design parameters needed can be achived witha prefab (we working on this - we have tested a lot of brands in different experiments; taken bandsaws to them; etc etc; to determine the different charcateristics of different brands and models)

    Watch this space...
  14. Craig:

    Just a little note from those of us who are daily in the trenches fighting with insurance companies to pay for orthoses for our patients. Even though I am in favor of research on orthoses and understand how Karl Landorf's research may show that OTC inserts may work as well as some types of custom foot orthoses in the treatment of plantar fasciitis, do you and other researchers then know what insurance companies will do with this research information?? They will put their own "spin" on Karl's hard work at researching orthoses to say the following: Why should we pay for custom foot orthoses for the patient with plantar fasciitis since Dr. Landorf's research has clearly shown that custom foot orthoses are no better than OTC inserts? They will then say that since OTC inserts do not work for the patient then the only reasonable next step, if OTC inserts fail for the patient, is plantar fasciotomy, not custom foot orthoses.

    I make this statement not for taking the steam out of Karl's fine research, but to make sure when such research is written up for publication, researchers realize that insurance companies and governmental authorities are always looking for ways to save money and not pay for valuable services, often at the expense of the feet of our patients. This is vitally important so that those of us who, every day, see patients that have plantar fasciitis or patellofemoral syndrome that have not improved with OTC inserts and then are improved within days to weeks with custom made inserts are allowed to continue providing our patients with a time-tested, valuable service that is covered by the patients' medical insurance (that they spent their hard-earned dollars on) so that they can more likely receive the benefit or custom foot orthoses, when medically necessary.

    Believe me, it is getting worse and worse all the time here in the States and it seems like more and more patients are having to pay cash for their orthoses since their insurance companies are not paying for them like they previously had. Having patients pay me directly for orthoses actually is better for the bottom line for my practice, but is far worse financially for my patients. Please give this a good consideration when discussing the efficacy of OTC foot orthoses vs custom made foot orthoses since the insurance companies and governmental authorities are always looking for excuses to deny effective treatments to patients being treated by ethical practitioners.
  15. Craig Payne

    Craig Payne Moderator

    Kevin - I agree totally, but in the context of evidence based practice, the 3rd party funders are getting on stronger ground when no studies have been able to demonstrate that custom made foot orthoses provide better outcomes.

    I recently emailed Chris Mac (PFOLA President) about this asking when the next PFOLA grant round is, as this is an urgent research question that needs to be addressed (and PFOLA needs to address the political side of it).

    One of the key critiques of the RCT's is the choice of custom made device, the prescription protocol and manufacturing protocol. Karl, quite rightly, used the custom made device that was most widely used in Australia at the time. For eg , if a different prescription protocol was used, would a different result have been obtained. Funny thing is that Karl's critics say yes, but I wish they could explain to me how they know that? Our first attempt at comparing presciption protocols showed no difference between them (all subjects got the same prefab, but one group had them modified according to a strict protocol that should have led to better outcomes, but did not.

    That does not mean that there will not be evidence in the future (and we ready to move as soon as we can obtain funding to pursue this)
    Last edited: May 5, 2006
  16. Craig Payne

    Craig Payne Moderator

    BTW - I do not know why the insurance companies/3rd party funders have a concern. Custom/prescription made devices are less expensive.
  17. Cameron

    Cameron Well-Known Member


    >Why should we pay for custom foot orthoses for the patient with plantar fasciitis since research has clearly shown that custom foot orthoses are no better than OTC inserts?

    That action was taken by health insurances here in Western Australia, a few years back. The insurance company quoted Root's paper where he quite rightly stated that bespoke foot orthoses are not a panacea. (excuse my paraphrasing), and they withdrew coverage.

    There was an articulate response from the profession but that met with little success. It was clients of the insurance company who complained bitterly about expectation of having the option for bespoke orthoses when they signed on for their insurance which eventually saw the company back down.

    So there is already precedent and the research findings from RCT are more significant.

    No question of doubt insurance companies will jump at making economies (another reason why this happened in WA was due to the spike caused by new providers, over prescribing), so yes I would agree it will become more difficult to justify use of the expensive prescriptions when OTC does equally as well. This will not stop consumers exercising their right to pay for made to measure foot orthoses out of their disposable income but when "the penny drops" in the corporate world this could have immense implications for practitoners across the globe.

  18. Sean Millar

    Sean Millar Active Member

    The use orthosis should not be viewed as an emotive decision made by the Podiatrist. Ethically the client should be given enough information regarding, pros, and cons including costs, of cast vs prefab. If the sujbect is presented in and objective way to the client, then surely the client makes the decision and not the podiatrist.
  19. I can see why this is an enormous issue in the USA where reliance on insurance funding is a major factor in practitioner incomes, but the reality is that major health insurance providers the world over will always be looking to limit payments - such is the nature of insurance. One possible solution is a dedicated podiatry finance plan where the practitioner estimates the cost of care over a set period - usually one year - and the patient enters into essentially a payment plan with the insurance company for the projected fee plus interest. This is how Denplan works for the UK dental profession and is much less sensitive to market fluctuations than straightforward health reimbursement insurance.

    This issue of custom made -v- OTC devices has fascinated me however. In the Rothbart debate Kevin said:
    I would assume from that statement that providing the diagnosis was correct and the manufacturing process sufficiently robust, then custom devices would be measurably more effective than prefabs....but the evidence from RTCs suggests otherwise. Why is this so? Could it be variations in standards of practitioner competency? Or variations in the lab process? Considering all the factors that could influence outcomes, how much weight should the profession give to this research? Is there any published work that shows custom devices are significantly more clinically effective than prefabs?

    At the end of the day I agree it comes down to patient choice, but are we giving the patient all the relevant facts?
  20. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    OK Craig - I'll bite, I can see you're dying to provoke comment here.

    I totally agree with you on the basis of chronic problems which require long term therapy...do you have any other economic principles that would explain the cost/benefit ratio in favour of custom orthoses for other situations?

  21. Phil Wells

    Phil Wells Active Member

    I'm with LL here (You do look as though you are trying to get a repsonse), what is your argument re custom made being less expensive?
    In the UK, the cost of an Interpod device v's a cutom made device is significant in favour of the Interpod. I can definatley see that the long term costs of a Direct Milled one peice devices may be more cost effective over a period of 5 years (possibly but no data to prove this as yet) but comments thrown back at me when I say this is that maybe the patient does not need the same prescription for 5 years?

    Last edited: May 5, 2006
  22. Craig Payne

    Craig Payne Moderator

    Yes, I was trying to provoke a response.

    Prefabs do not last as long as custom made and need to be replaced if therapy needs to be for longer term. The point I am making is that so many make the argument of difference based on cost, when its not necessarily a factor. (I just recently replaced the top cover on a pair of polyprops that were first issued ~20 years ago --- there was nothing wrong with the shape of them).

    I have just have had several emails about one of my posts being posted over at TFS ... went and had a look at the thread.... they confirm exactly what I am saying ---- look at the slagging off of the "expensive" custom made devices ---- ie arguments based on cost and no arguments on what prescription variables are needed by the patients and the best way to provide those variables.... at least the responses here are intelligent :cool:
    Last edited by a moderator: May 5, 2006
  23. Phil Wells

    Phil Wells Active Member

    As I havn't got access to the research on Pre-fab verse Bespoke, can anyone help me with the question as to how relevant are the subjects used compared to the patients we see in our clinical practice.
    My querry is due to the fact that I prescribe almost exclusively bespoke orthoses due to my client group being the more challenging types. In the past I have used pre-fabs very successfully but very rairly see a foot type or condition that I feel is appropriate for their use now.
    Has any one done a pre-fab verse custom ortho RCT on Chracot patient's or severe RA patients.
    The generalisation re ortho's that people draw from this research is very worrying for future orthotic provsion for the demanding foot type.

  24. DaVinci

    DaVinci Well-Known Member

    In a thread on ethics, you say you have not read the literature
    yet you criticise the conclusions:
    I am not a literature officanado, but have seen and heard enough of the published research (and heard Craig and Karl present on the unpublished stuff) to hope I appreciate what is going on. Its called evidence based practice (ie being ethical). As Hylton Menz said in another thread:
  25. Craig Payne

    Craig Payne Moderator

    Maybe that the answer that Mark was looking for in message number 1:
    ...it sort of was the point I was trying to make.

    Phil - In all our RCT's and Karl's biggie all the subjects had the usual everyday variety of plantar fasciitis.
  26. Cameron

    Cameron Well-Known Member


    If the evidence favours niether one over the other, then we may assume they both serve the same function. Natural inquisitveness would direct enquiry as to what they have in common. Accepting some versions may outlast others (a definate convenience) by in itself is no real justication.

    Foot orthosis (a la Root) as I understand offer three levels of support frontal plane planer balance, sagittal plane support to the arch leading up to heel off (which may assist the Windlass action and help resupinate the stj); and plantar foot accommodation.

    No matter how the shell, posts and soft tissue accommodation are contrived, provided they meet the above criteria then they would at the very least function.

    What say you?

  27. Cameron

    Cameron Well-Known Member


    Part II Intrinsic posting

    I have just taken the dog for a walk.

    I believe, (who am I?) the effects of the foot orthoses are dependent upon a combination of the foot to orthosis inteface; the orthosis to shoe interface and the shoe to gound interface. Other extraneous variables and halo effects taken into account prediction of behaviour is difficult to say the least. The sub talar neutral shell relates its shape to barefoot walking on a flat surface which has absolutley nothing to do with movement in shoes. However working on the premise of safe paramenters maintaining middle range motion in the main gravitational joints would preserve end of range motion and possibly reduce repetative stress associated with pathological changes. This is borne out by anedotal evidence and foot orthoses can be useful in reducing related pains in the leg e.g. shin splints.

    But independent evidence prefers the same effect may result from OTC foot orthoses so we may have to accept a neutral shell has the same effect as a posted shell (particularly when the posts were made from compressible materials).

    Most of the newer innovations in orthotic prescription (post 70s) have come from labotoratores (in vitro) and relate more to the ease of manufacture than any measurable benefit to clients (the absence of in vivo evidence would support that statement). Something which I believe has never been questioned is the validity of intrinsic posting. Whilst it may be a convenience in manufacture, interferance with the foot to orthotic interface in the instrinsic structure of the foot orthosis may detract from its efficacy. Worth a thought

    Something which is often evident in bespoke foot orthoses across the globe is the absence of new materials. Preference instead is given to what is familiar to the practitioner and or manufacturer. The age old debate about a replacement for Rohadur for example still prevails decades after after the product was withdrawn and replaced with Plexidur O (exactly the same material minus the orange colouring additive).

    By contrast OTC foot orthoses do incoprporate new polymers which may again advantage them over bespoke devises.

    As always, what say you?

  28. I agree that there are many variables that don't apear to be currently considered when evaluating the prescription for foot orthoses. Simon points out earlier in the thread that the foot doesn't always remain in contact with the device during the gait cycle - what effect does that have? There are other factors too - heel wear on the shoe must vary the GRF & rear post angle; heel construction - solid or lattice; shoe counter - rigid or soft, to suggest a few. Understanding of anatomical structures and their mechanics may have progressed but how many practitioners factor the variables when determining their prescriptions?

    Also there is a weakness in the current design of foot orthoses given that they work predominately by acting on the GRF. Where there is an intrinsic foot defect such as disruption of the medial ankle ligament, a plantar foot bed alone is often insufficient - not to say uncomfortable - to restore function. Recent developments in silicone technology which have been incorporated into AFOs may give us the next phase in custom devices - retaining the benefits of current foot-bed design whilst giving dorsiflexion support/enhancement during the propulsive stage.

    For example see:


    Any comments?
    Last edited: May 7, 2006
  29. Phil Wells

    Phil Wells Active Member

    Da Vinci
    I was not critising the research, only the conclusions (Including Insurance companies) that people take from it.
    I think these are valid querries as ortho's are extremely complex and include many variations. We need to be aware that not all orthos are EQUAL
    Last edited: May 8, 2006

Share This Page