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Failed orthotic therapy

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Simon Spooner, Oct 20, 2014.

  1. Members do not see these Ads. Sign Up.
    I always enjoy it when a patient pulls out a few pairs of failed foot orthoses at an initial consult, not. I can't remember more pairs than this from one patient though.

    Attached Files:

    Last edited by a moderator: Oct 21, 2014
  2. Griff

    Griff Moderator

    I see your eight and raise you one.....

    Attached Files:

  3. Jeepers

    I can't come close to that did have a patient 3 pairs using the exact same prescription, excact same negative, still no change in outcome. Wonder why ;)

    I have started re-booting these types of patients, they want help, but are so negative even if you work out what went wrong multiple times the chances of success is less, due to the negative mindset.

    Remove everything, come back in 3-4 weeks and we start from scratch, if there is no pain or complaint no new device, after that conversation I find I am talking with a more open patient.

    You almost see them thinking wow this guy didn't even try and sell me anything
  4. David Smith

    David Smith Well-Known Member

    Good Tip
  5. Paulbarrett

    Paulbarrett Welcome New Poster

    Why would a patient buy 8 / 9 pairs of orthotics - especially if the first pair has not worked!!! Why would they not go back to the practitioner who sold them the first pair.

    Also, I would say that any of us that prescribe insoles will have a few pairs on other practitioners plynth's at some stage because they have not worked.

    I don't look at that as failed orthotic therapy - more failed patient follow up care.

  6. Paul Bowles

    Paul Bowles Well-Known Member

    You are making the assumption that it is the orthotics that actually fix the problems - there is the issue.

    If all carpenters have the same tools, why are some better than others then?

    Its the practitioner that makes all the difference, the orthoses are just that....orthoses. They dont fix everything and in isolation rarely work.

    Over prescription of orthoses is a problem. Ive had similar experiences to Simon above. 8, 10, 12 pairs off 4 different Podiatrists. The first question I have is what was the 2nd, 3rd and 4th Podiatrist thinking and how do I not make that same mistake!
  7. Boots n all

    Boots n all Well-Known Member

    How could so many get it wrong so often?

    Maybe its not the fault of the orthoses or the practitioner, rather the client trying to make them work in inappropriate footwear?

    None of them are going to work in a pair of 6 inch heels or a sling back:rolleyes:.
  8. I have seen this many orthoses from one patient too many times to count over the past 29+ years of podiatric practice. Here is what I do.

    First of all, I ask them which orthoses have worked the best of all those they brought with them. Then, by looking at their construction, I determine which one of these orthoses most closely matches the shape and material characteristics of an orthosis that I may make for that patient.

    Secondly, after getting a diagnosis and comparing the congruency of the orthosis to their foot, and the stiffness characteristics of the orthosis, I determine which orthosis modifications need to be made to best relieve the stress on their injured structures (i.e. Tissue Stress Approach). I will then make these modifications temporarily with either grinding or adding adhesive felt to the orthosis to make the orthosis work better for the patient.

    Third, I don't charge them for making their existing orthosis work better (95% of the time I can make it work better with less than 5 minutes of work on the orthoses in my office). Instead, I just charge them for a standard office visit. However, I do let them know that I can make a better orthosis for them in the future if my modifications do work.

    Fourth, I schedule them back in 2-3 weeks to see if they are making improvement and at this time will either make the temporary orthosis modifications more permanent with korex glued to the orthosis or will evaluate and cast them for a new foot orthosis, depending on the patient preference.

    There is no hard sell here. My goal is to allow them to better understand that I know enough about foot orthoses and foot and lower extremity biomechanics to make even non-functional orthoses work much better with only a small amount of my time so their confidence is again restored in custom foot orthosis therapy. I could care less whether they go with just modifying their old orthoses or go with having a new orthosis made. As long as they are improved or healed with my treatment, then I consider my treatment goals to have been met.
  9. efuller

    efuller MVP

    Yes, there are conditions that you cannot successfully treat with an orthosis. Other times, the bagful of devices all made the same mistake. I remember well a patient I saw around my second year of clinical practice. He had a bag full of orthotics. He had been in a motorcycle accident and had his forefoot fused in varus. All of his orthotics ended behind his metatarsal head. I made a device that had a large forefoot varus extension. I'd never been hugged by a patient before. There were many lessons from that patient. One lesson was that devices that end behind the metatarsal heads cannot support a forefoot varus. Another lesson was that you need to look through the pile of orthotics to see if one was made that addressed the patient's mechanical issues.

    If the patient has an orthotic that was made just as I would make it, I certainly won't repeat that mistake. As, Kevin pointed out, I can often quickly modify an existing orthotic to change the orthotic to make its design closer to how I would make the orthotic. If the patient feels better with that modification, then, depending on the modification, the patient can go on there way, or get a device that will last a lot longer than a 5 minute modification.

  10. I generally concur with Mike, Kevin and Eric's approach. In this case the patient presented with plantar fascitiis and mild-moderate hallux valgus, her expectations were a reduction in pain and if possible a slowing of progression of the hallux valgus. We discussed the evidence base and I took one of the pairs of orthoses which I thought demonstrated the best shell design, added some design features with the intent of lowering the hallux dorsiflexion stiffness- first ray cut-outs and kinetic wedges. I'd have liked to have added heel lifts too, but the patient was concerned of shoe fitting- softly, softly... experience dictates that these type of patients fall into a similar personality type and a gentle coaxing is often required. Frightening how close Kevin, Eric and and I are now aligned on our approach to this kind of patient care since my protocol with this patient is pretty much identical to what Kevin and Eric described above- we've been hanging out too long guys.

    Of interest, some of the devices she had been sold as "made to measure" foot orthoses were clearly prefabricated shells. She told me they had been prescribed using a pressure mat- she beleived them to be custom, when I explained to her she said her husband had already pointed out to her that you can't make a 3D shape from a 2D pressure reading- clever husband.:rolleyes: £200 ($322 US dollars) for a pair of prefab shells with met dome and topcover??? Go figure. So who is in the wrong here? Does the prescribing practitioner know they are selling prefabs as customs, or is the lab pretending to send out custom devices and the practitioner just not smart enough to twig on? For the record, I have first hand experience of a lab operating in this way- I worked for them; always surprised me how few practitioners complained- Dave Tollafield did, never forgot that- he sent casts of cavus feet as a "tester" - smart guy. The word "customised" rather than "custom"= semantic deviancy. Even the devices that this patient presented with that looked like they were custom appeared to have been "mirrored" in the CAD; who's fooling who here? As I pointed out to the patient, pre-fabs and mirroring might be OK as long as everyone is honest and up front about what is being sold. At least the practitioner that sold her the prefabs at the bottom of the image was honest about what was being sold.

    As I said many years ago on the old mailbase: "Too many people in it for the money, too many people who don't have a clue what they are doing". Time for the industry to be regulated.
  11. CraigT

    CraigT Well-Known Member

    As do I.

    The fundamental problem here is that practitioners/patients think that it is the orthosis that 'fixes' the problem. It is not- it is what the orthosis does that provides the benefit.
    An orthosis should be designed to perform a function, then it should be reviewed to assess whether it is performing that function. If it isn't, then why not? Is it the design? Other factors?
  12. CraigT

    CraigT Well-Known Member

    I get the impression many CAD orthoses do not necessarily use the scan apart from getting the size and the arch height... an advanced library type device really.
  13. Which is fine, so long as all parties are aware of this: from the lab down to the patient. The problem is most patients do not have the requisite knowledge to discern the fact from the marketing neither do some practitioners.

    I used to scoff at Ray Anthony making practitioners go on a prescribing course before he would allow them to use his lab; I saw it as a money making venture on his part. Now that I'm older and a little wiser I can see that Ray's approach was probably far superior to the situation we are faced with today in whch the available technology makes it possible for anyone with the wonga to set up a commercial lab without any real knowledge of foot orthoses therapy; anyone being able to prescribe foot orthoses; and an unwitting public often being used as cash cows.
  14. Paulbarrett

    Paulbarrett Welcome New Poster


    To be honest I have seen a fair few RX devices through my door over the years - made by practitioners who have been on his prescribing course! Is that Rays fault or is every failed device due to stupidity on behalf of the practitioner? Maybe the practitioner has made 100 of these insoles with great patient satisfaction and these are the first two to go wrong?? I know they are a good device when prescribed properly.

    I think that we will all agree that an orthotic has a functional role to play but it is limited and based on many extrinsic factors - some of which have a large bearing on the outcome for the patient, as touched on by David -do they do their stretching, have they modified the footwear, have they broken them in properly etc.

    I liked the ref to the carpenter Paul - and you are 100%, its a sliding scale - you get older, you get wiser you should make less mistakes. I don't mind it so much if someone comes in with insoles as like Kevin - I will generally be able to use these to create a device that works and save the patient some money and it is a challenge to figure out how to correct the problem and not make the same mistakes.


    We are all in it for the money Simon…..some want/need more than others but we all have to earn it. But I agree about the regulation.

  15. blinda

    blinda MVP

    None taken.

    Yep, me too. Despite being a girl ;)

    Actually, my income was higher in a previous career, but my job satisfaction far exceeds any financial gain.
  16. Paul,
    Welcome to Podiatry Arena. Is this you? http://www.insidetm2.com/customers/feet-24-7-ltd I see that you were formerly clinical director with TOG orthotics, congratulations on your new business.

    No, the practitioner using Rx devices will have made zero of these insoles, since Rx was a commercial lab employing it's own manufacturing team. Thus, the practitioner has to trust that the lab are providing what has been requested upon the prescription/ order form. As I stated previously, one of the issues of trust is whether or not the lab is providing true bespoke devices when requested and not merely taking a few measurements off the negative using a ruler and then using a prefabricated shell. The discerning practitioner will be able to tell the difference, someone less experienced may not. Another issue of trust is that the lab are not mirroring devices, nor using a library system when true bespoke devices are being ordered and paid for. Finally, the practitioner has to trust that the lab has followed the prescription to the letter.

    Indeed, but also the patient who is paying for a bespoke device, should expect to receive a bespoke device not a glorified prefab, agreed? Moreover, the patient should be able to trust that the prescribing practitioner has the prerequisite knowledge to prescribe a device which has design characteristics which are most likely to result in a positive outcome for their complaint, agreed?

    This is not strictly true either. I know of a large number of clinicians who get paid the same whether they prescribe one pair of orthoses per week or 60. There is no vested interest among such individuals in over-prescribing.

    Then there are the clinicians who knowingly pass off glorified prefab devices as bespoke devices and charge the patient the going rate for bespoke devices- have these clinicians "earned" the excessive fee they have charged?
  17. Mine too!

    I knew I recognised Paul's name- he called himself "foot soldier" here:

    But it turned out that "foot solider" was really Sean Savage: http://www.podiatry-arena.com/podiatry-forum/showpost.php?p=68478&postcount=43

    I never did get an apology from Paul Barrett. Like I said Paul, welcome to Podiatry Arena ;-)

    Here's the original thread on TOG orthotics in its entirety: http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=3580
  18. Much seems to be focused on tne practitioner, might be of interest to think all the stages prescription can go wrong

    *wrong information from patient

    *wrong diagnosis

    * bad casting

    * wrong prescription of device

    * poor manufacturer of device /techniques used

    * manufacturer not following practitioners requirements

    * patient not following instructions such as poor shoes etc etc

    *device not able to reduce forces on tissue enough to reduce symptoms

    *tissue damaged more than 1st thought

    anymore ?

    really is a process that requires a lot of skill and working with the right people.Or doing most of it yourself. Then it becomes a question of education
  19. Problem is, at the moment anyone can do it.

    I know: the lab can blame the practitioner for not prescribing it right, the practitioner can blame the lab for not making it right, the practitioner can also blame the patient for not wearing it right and the patient can blame the practitioner for not getting it right. :morning: That way everyone is unhappy and that's alright, right?

    At least that way we can all:

    You’re gonna sleep like a baby tonight
    Not everything can be so black and white
    There are demons in the broad daylight
    But you can sleep like a baby tonight.

    Sleep tight.
  20. Deka08

    Deka08 Active Member

    Simon, out of interest, would you highlight the pair that you modified to suit your ideas, and if possible, take a pic of what it looks like after the mods? I know the pt in question probably has them, but i assume she will revisit you for a review. And if you do manufacture your own set for her, could we see the final product there? It would be intersting to see the journey of transition from device to successful device.
  21. I used a pair of the natural coloured milled devices, second down on the right hand side of the image. The patient has the devices. I ground in first ray cut-outs added a 3mm high density EVA full length topcover and kinetic wedges to both. I have a review with her in a couple of weeks. You are making the assumption that my modifications to the devices will be successful, we will see. If nothing else, at least I can provide a theoretically coherent rationale for my actions.
  22. CraigT

    CraigT Well-Known Member

    You will have more feedback... There is an advantage of having a bag full of orthoses in front of you- you can see what hasn't done the job.
    Another thing I will often do is use foot taping to be assured of a therapeutic effect with the change in mechanics.
  23. In the past month, I have had an experience in my practice which has occurred rarely.

    I've had two competitive female distance runners in the last month (the one I saw yesterday is quite well known), over the age of 50, who came in with foot problems that other very good podiatrists have treated with orthoses. What they wanted for me to do was to take their history, examine them, look at their multiple pairs of orthoses and diagnose them, and totally refurbish their foot orthoses for them on the spot, all during the initial office visit. When I tell them I can't do all of this in one office visit since it would take an extended period of time to make the proper orthosis adjustments they needed (since it would have likely taken me over 30 minutes to do what they wanted me to and I was already seeing over 30 patients that day and had a very tight schedule), they have both told me that they will be seeing, instead, their other podiatrists who will cater to their orthotic adjustments during an office visit.

    If I was less busy, I probably would have been able to meet their demands to try and keep them happy. However, on an initial office visit, there is only so much I can do in the time I have allotted to take a history, examine them, watch them walk and run, look at all their orthotics. I simply don't normally have enough time to do more complicated orthosis refurbishments on new patients when I'm so busy.

    I suppose that I'm just venting here that these two female runners had the expectation that I should have taken an hour of my time to do everything they wanted me to do in their initial office visit with me when I only could give them half that time so I would not be late by at least 30 minutes with all my other patients after them that day. Is this a problem others are seeing in busy sports podiatry practices, or is it just me and my practice??
  24. I guess the question I am asking in my last posting is what do others do when such a situation arise?

    Do you always accommodate the patient and make all the adjustments right there in the initial office visit even though those adjustments may take 20-30 minutes to make? (i.e. How do you plan for such an event in a busy practice?)

    Or do you tell them that you can do it but it may take a few days to a week to find the time to make the necessary repairs to their existing orthoses?

    I am interested in what others do in similar situations.
  25. I accomodate but I book one hour for initial consult for most musculoskeletal patients hence I usually have time.
  26. I am simply too busy to allow an hour for initial visits. Maybe that is the problem. I'm averaging 30+ patients per day so an hour initial office visit simply isn't possilbe. However, 15 years ago, I could probably have done it when I was only seeing 15-18 patients a day.
  27. Is it worth your while having an on-site technician who can do the modifications for you then?
  28. FWIW

    I have 1 hour times, 30 min and 15 min depending on what is booked

    1 hour for new patients/biomex assessment
  29. Probably not since it just isn't that often that I need major refurbishments being done on orthoses. In addition, I simply don't think I can train a technician to do what I can do with an orthosis in a reasonable amount of time. Patients will just need to learn to be patient, and wait a day or two for major refurbishments, or go elsewhere. My practice is very busy now so I don't think it is a problem if I lose a crazy runner patient or two along the way since I won't stop my busy practice for their whims on my initial visit with them.
  30. efuller

    efuller MVP

    I wouldn't go so far as to call them crazy. They just want to be efficient with their time. It is an expectation problem. They are expecting to get their problem fixed in one visit. The difficult part is having your scheduler recognize, and explain, the difference between their expectations and the reality of your office.

  31. Lab Guy

    Lab Guy Well-Known Member

    Those type of patients think the world evolves them. They are more interested in getting their orthotics refurbished on the first visit than appreciating the extensive knowledge and experience your providing them to obtain an optimum long term result. I say they are not deserving to be your patient.

  32. The term "crazy runners" does not mean that I think that all runners are "crazy" but rather, it means that some runners, can be quite odd , unusual and even demanding at times.

    The problem with your idea, Eric, is that there is no way for my office staff to know if I can fix a runner's problem in 15 minutes or in 3-4 thirty minute office visits until I have actually seen them for the first time. Patients are never told that I will be able to take care of all their problems in one visit by my staff. If patients somehow have that expectation when they see me for the first time, then they have dreamed up that hope all by themselves since my staff and myself would never tell a new patients this.

    I do agree that a few runners have very unrealistic expectations of what I can do in one office visit. However, most runner-patients are very reasonable, intelligent and understanding. It is the demanding ones that don't seem to understand that all running problems can't be fixed in just one office visit that I have an issue with. These runners generally end up going elsewhere since I won't stop my practice and hold up my other patients' treatment just because they have unrealistic expectations of how a busy doctor's office works.

    My favorite one this week was a well-known runner who has bilateral flatfoot deformity and complained of knee and hip pain. When I tested out their posterior tibial (PT) muscles, they had absolutely no PT muscle strength and somehow had ruptured both PT tendons. When told this, the runner disagreed with me that they had ruptured their PT tendons and said "I couldn't have ruptured my PT tendons!". I told them to get an MRI scan, they said they couldn't afford it and didn't understand why they were now pronating through an orthosis that worked very well previously for them.:craig: Since they didn't want to believe me that they had ruptured both PT tendons, then I sent them back to their old podiatrist to see if they agreed with me or not. Go figure!!:bang:
  33. Blarney

    Blarney Active Member

    It still amazing that no one addresses the issue that orthotics don't change foot alignment and joint positional changes that have occurred over time.

    How can you hope to improve compromised foot function just by placing an orthotic in a shoe?

    That's the main reason I see for a patient arriving with a bag full of orthotics - let's improve joint alignment and function with hands in mobilisation and manipulation combined with exercises and then only if needed use orthotic to support this correction.


  34. Griff

    Griff Moderator

    Changing foot alignment and joint position is not high on my agenda when I issue foot orthoses.

    That aside, is there a strong body of evidence that manual therapy (as you describe it above) will reliably result in these changes Justin?
  35. Dennis Kiper

    Dennis Kiper Active Member

    The problem is not the practitioner, the lab or the patient. Failed orthotic therapy in the numbers you are writing about is mostly due to an outdated technology.
    It is inconsistent, inaccurate and doesn't match the true biomechanical function of the gait cycle.

    Fitting an orthotic to the shape of the foot and adding one or more modifications does not meet the biomechanical loading criteria of most any foot, minus some anomalous conditions.

    “An orthosis should be designed to perform a function”-- I do not agree with this, in my opinion an orthotic should guide the foot through a healthier biomechanical efficiency, by reducing, slowing down and minimizing the “natural” pronation ROM from heel contact through heel off, and maintain dynamic stability of the rearfoot, midfoot and forefoot. Traditional orthotic technology does not do this very well, but rather inhibits the smooth biomechanical function of the gait cycle. If orthoses technology were more scientific and quantitative, the industry could be regulated because then you'd truly have a Rx orthosis.
  36. Ahhh the pronation is the Root of all evil in Gait and science discussion, round and round we go.
  37. blinda

    blinda MVP

  38. Lab Guy

    Lab Guy Well-Known Member

    Another interesting thread poisoned. Sigh

  39. Dennis Kiper

    Dennis Kiper Active Member

    Ahhh the pronation is the Root of all evil in Gait and science discussion, round and round we go.

    No Mike, pronation is not the root of evil in gait, it is the instability in the biomechanical loading that is the problem.
  40. Dennis Kiper

    Dennis Kiper Active Member

    Changing foot alignment and joint position is not high on my agenda when I issue foot orthoses.

    Changing joint alignment should be the highest priority of an orthosis. Joint congruency translates to better mechanical efficiency.

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