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Orthotist/Prosthetist Manufacturing Orthotics for Podiatrists...

Discussion in 'Biomechanics, Sports and Foot orthoses' started by JaY, Jul 8, 2011.

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  1. JaY

    JaY Active Member


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    I have recently become part of a company of podiatrists that use the skills of an orthotist/prosthetist to make the orthotics that we (as podiatrists) prescribe for our patients.

    I am not entirely happy with the orthotics that come back from him...they just do not seem to be the "same" as orthotics that are manufactured by a podiatrist?!? I think this has to do with the fact that podiatrists and orthotists/prosthetists were simply taught differently... :bang:

    What are your thoughts on an orthotist/prosthetist making orthotics for podiatrists?
     
  2. The correct orthotic for the correct foot ..... so any device will work

    The problem becomes if you on´t get what you want and then you need to talk to the guy making them
     
  3. That is quite true. But can I suggest that you may have hit the wrong emoticon? I think that should be :drinks rather than :bang:. Its a good thing that there is diversity of method and paralell evolution. We have a lot we can learn from each other if we can get over...

    You're correct again. Orthotist orthoses are sometimes not the same as Podiatrist insoles. But that by itself is not a good reason to be unhappy with them. Have you had time yet to start seeing outcomes? Is your unhappiness based on a specific complaint with the insoles coming back?

    From my experience, orthotists use many of the same ingrediants as us but sometimes bake a very different cake. And from experience that cake sometime tastes damn good. I've visited both podiatry led and orthotist led commercial labs and I learned a great deal from both. They come to orthoses without a lot of the dogma that we're lumbared with and have some very good ideas and mindsets.

    That's not to say the insoles you're getting are better, they might be dross. But don't prejudge them JUST for being different. Have a chat to your orthotist. Have a chat to the lab producing them. Maybe see what some of the returning patients say.

    Most (not all) of the orthotists I've encountered are really rather good.* Get to know him, spend some time with him. You may even find you learn something. But one simply cannot give a general answer about "orthotist produced insoles". They, like us, are a diverse profession with lots of variety of style and types of device.

    Kind regards
    Robert

    *Except for Robin, who smells of damp rabbits. ;)
     
  4. Griff

    Griff Moderator

    You could always talk to the Orthotist about this concern? I dare say you could both learn a lot from each other. Remember we as Podiatrists don't own the monopoly on foot orthoses - and there are plenty of Podiatrists who can't make devices for toffee.

    Looking forward to RobinP reading this thread...

    EDIT: Ooops, cross posting with Isaacs there - basically the same
     
  5. Your joking right ?

    in 2 different countries the orthotics that I see coming from 99% of orthotist are exactly the same prescription

    full length EVA with a met dome - which is the only cast modification or casting modification done - ie they put some wet plaster on a foot and let it hang, or foam box by pushing the foot into it.

    I know Robins different and maybe England different but Australia and the 4 countries of Scandinavia as a rule this is what Ive seen and I know it´s how they are taught.

    works for some feet - not for others
     
  6. Fair point.

    Ok, DIFFERENT dogma.

    Happy with that?
     
  7. Yep off the paint the house :drinks
     
  8. RobinP

    RobinP Well-Known Member

    OOOOhhhh Rabbits......I loooove raaabbiiittss:drinks

    JaY,

    Answering this risks delving back into the depths of what constitutes the best training for people who intend to be putting orthoses in people's shoes. I'm not sure about South Africa, but in the UK, there are some hospitals that are podiatry led and others that are orthotist led. Obviously, I have only worked at Orthotist led ones. However, chiropractors, physios, FHPs and random sales people all fit orthoses. I'm sure the list could go on. So, as Ian said, podiatrists don't have the monopoly on fitting orthoses. That being said, my opinion would be that they are by far and away the best placed practioners to be doing so.

    Orthotist/Prosthetists have a pretty sound knowledge upon leaving University about Biomechanics. Ask a P&O graduate what biomechanics is and a podiatry graduate what biomechanics is and you will get 2 very different answers. Biomechanics to a P&O graduate is the study of forces and their effect on the body. As we deal with prescribing devices/limbs for the whole body, very little is focused upon the feet.

    A podiatry grad will generally talk about biomechanics with reference to the foot/ankle and treating lower limb pathology. In my opinion, podiatrist understanding of lower limb anatomy is far superior to most orthotists, but orthotists understanding of the general principles of biomechanics(the subject) is probably a little better.

    The other thing that sets the two professions apart(and this is where I start to become a little disheartened with my own profession)is the way in which we tackle problems. Podiatrists are pathology led as a profession. Podiatrists see patients who are generally in pain and instinctively look for a pathology. Orthotists are not taught to do this because, on the whole, we are not primary care professionals. We will have a patient referred by an Orthopadic Consultant diagnosed with "x condition - please sort them out" As a result, we do what most surgeons do which is to try and restore normal function, instead of treating the patient's complaint. If you are a follower of tissue stress theory, this can be difficult to comprehend.

    In addition, I still don't think that Orthotists (clearly this is a sweeping generalisation) quite grasp the concept of kinetics vs kinematics in lower limb pathology. The understand kinetics and they understand kinematics, but not the interrelationship. I say this as a result of personal experience, because until 2 years ago, I didn't get it either.

    Now that I think I have given you an idea of why our 2 professions think differently it will hopefully give you a little more understanding of why manufacturing styles are different.

    Mike is spot on here. You don't find many orthoses in Germany without a met dome which has always been beyond me. In England, I think the majority of orthotists use EVA devices with very little in the way of modifications. I did for many years and was reasonably successful in my outcomes, but I had no idea why some things failed and why others worked a treat. That was my lack of understanding of kinetics with regard to lower limb pathology. I now know and I still use plenty of EVA devices, just in a different way.

    This is the crux of it my opinion. Most orthotists have reaonable outcomes, even with very simple flat insoles but they actually don't understand the mechanism of the success. The reality is that many of these patients may have done just as well with Formthotic or other prefab stuck into their shoe by a physio assistant/nurse/consultant.

    If you ask most orthotists to explain SALRE/ 1st MPJ/Windlass Mechanism or the reason why supination resistance is important or even to determine why joint stiffness is more important than the ROM, I'm pretty sure they will think you are talking a whole load of podiatry mumbo jumbo. It is because they will most likely not really have encountered it at Uni in any great capacity. I suppose I don't have much of a problem with this. There is a limit to how much can be taught in one curriculum and the scope of practice is quite varied so a basic grounding in most areas is what is taught. Most orthotists just don't pursue it much further than that. Which, for a profession doling out millions each year in orthoses is quite short sighted.

    My guess as to why your lab don't seem to be doing things right.... they don't understand you because they don't understand the principles of treatment. You need to speak to them to find out if they understand SALRE (if you are using medial heel skives), if they understand your use of lateral forefoot wedging(if you are deliberately trying to alter COP), if they can understand why you might not want any arch fill or if you are doing a Blake style why you might need more. Like I said, they probably don't because most of the orthotic led labs that I know of don't understand this.

    If they are good guys, they might just take the initiative and start to change their practice and appreciate what you say. If not, you may have to go to the lab and describe in detail every bit of what you expect when you present them with a prescrition. I can assure that this is no easy task, especially when they don't believe a word you say.

    What they are doing is probably not wrong, because none of us really know for sure what that is. Most importantly, it is not what you want. Speak to them with an open mind, there might just be some things that you learn. Hopefully, they will afford you the same respect and consideration.

    Best of luck

    Robin
     
    Last edited: Jul 11, 2011
  9. R.S.Steinberg

    R.S.Steinberg Member

    This points out a glaring problem ie, each of us have a different knowledge base. The titles we use really only mean something in our own countries, for the most part. This leads to credibility problems.

    As for my opinion, in my 36 years in the full practice of PM&S, as a DPM, I have never seen a single well made, appropriate for the patient's condition, orthotic from an orthotist or "shoe store pedorthist, or from a Chiropractor or physical therapist. There is absolutely no parallel, or "use of same ingredients, except for thermoplastics, etc. To suggest their knowledge base is in some sort of parallel to a podiatrist or DPM, is without foundation. They lack a base knowledge to diagnose, and at best, hopefully can at least make an orthotic to a doctor's detailed prescription and plaster cast. (In my office, the Rx is an 8.5" x 14" form.) Again, I guess this is at least my learned opinion !

    And please, everyone, don't abuse the terms. An insole is not a Rx orthotic. An insole is anything you put in the shoe under the foot besides your sock ! ! !

    RSS


    You're correct again. Orthotist orthoses are sometimes not the same as Podiatrist insoles. But that by itself is not a good reason to be unhappy with them. Have you had time yet to start seeing outcomes? Is your unhappiness based on a specific complaint with the insoles coming back?

    From my experience, orthotists use many of the same ingrediants as us but sometimes bake a very different cake. And from experience that cake sometime tastes damn good. I've visited both podiatry led and orthotist led commercial labs and I learned a great deal from both. They come to orthoses without a lot of the dogma that we're lumbared with and have some very good ideas and mindsets.

    That's not to say the insoles you're getting are better, they might be dross. But don't prejudge them JUST for being different. Have a chat to your orthotist. Have a chat to the lab producing them. Maybe see what some of the returning patients say.

    Most (not all) of the orthotists I've encountered are really rather good.* Get to know him, spend some time with him. You may even find you learn something. But one simply cannot give a general answer about "orthotist produced insoles". They, like us, are a diverse profession with lots of variety of style and types of device.

    Kind regards
    Robert

    *Except for Robin, who smells of damp rabbits. ;)[/QUOTE]
     
  10. RobinP

    RobinP Well-Known Member

    Robert,

    Have you ever come across anyone, anyone at all who has had symptom relief from a Walmart our Running shoe store orthosis?

    This question is not directed at you mr isaacs
     
  11. Griff

    Griff Moderator

    Why??
     
  12. Nah. They weren't 8.5" x 14".
     
  13. RobinP

    RobinP Well-Known Member

    I've just re read the part of the post that says

    I misread it as it was on my phone - I thought it was a reference to the thickness of the polyprop used or something similar.

    I didn't realise it was a boast about the size of the prescription form.

    It's not the size that counts, it's what you do with it.....my wife tells me.
     
  14. I don´t have a prescription form - write whats required straight onto the white board when I pour the cast.
     
  15. Ian Drakard

    Ian Drakard Active Member

    So basically your whiteboard is your prescription form- just out of interest how big is it? ;)
     
  16. My guess bigger the DPM Steinbergs prescription pad :hammer:
     
  17. A indeed is to say that their knowledge base ISN'T parallel to a Podiatrist. Unless you have evidence to the contrary...

    Personally, I know orthotists who have forgotten more biomechanics than most podiatrists, and podiatrists who'd struggle to diagnose a broken leg. And indeed vice versa.
    Then you have been singularly unlucky.
     
  18. R.S.Steinberg

    R.S.Steinberg Member

    RobinP, Those, who on a lark, try an OTC insole, will "feel" better if they have a minor concern that is not cause by rearfoot to forefoot misalignment. THese OTC insoles mostly just sooth the plantar skin nerves. You know, that feeling you get when walking on plush carpet. In the USA, with an Rx orthotic, we are directly treating the ankle, as well. Someone who is happy with an OTC insole has no reason for further care for whatever the problem is, so why would they make an appointment? :boxing:

    All of this continues to raise more questions. We talk amongst ourselves, and the education seems to be very very different. A podiatrist in the UK or AU or NZ, is not trained the same as a podiatrist/DPM in the USA.

    The main problem I see with Rx orthotics made by orthotists, pedorthists, physical therapists, and chiropractors is they cannot properly correct forefoot to rearfoot misalignment. I also suspect that they cannot find STJ neutral. Further, when I cast patients and send the cast to a certified lab, the orthotics work to relieve foot, ankle, shin and knee pain. I suppose I could send the failed device to the lab for their opinion, but why. I am not in business to help those who have no business playing "foot doctor".

    My practice is 60% sports medicine, 20% foot & ankle surgery, 20% IGTN and verrucas. I have 36 years of hands-on treating patients in my private practice. While I do not know how other podiatrists are trained in other parts of the world, I suspect most probably are aware of our training in the USA. By no means am I trying to be disrespectful, but there are definite differences in our training. It's just that I have found it very hard to get a detailed description of courses, clinics, and medical and surgical residencies in other countries. The seemly wide world of differences make it difficult to base line of credible statements. If there were only a way to create meaningful international standards for the foot doctoring profession with out those standards sinking to the lowest common denominator

    Does any know of an article that describes the training. In the USA we have the CPME (Council on Podiatric Medical Education) who sets the standards. What do other countries have?
     
  19. Hi Robert, The bolded bit

    a serious question is this how you think and orthotic works by correctly the forefoot and rearfoot misalignment and that we work to getting the STJ towards ´neutral´?

    If not, how do you think Orthotic devices work to relieve symptoms ?
     
  20. efuller

    efuller MVP

    Interesting theory. I could come up with some others. If you were at the county fair would you buy a can of elixir that soothed the plantar skin nerves?

    In lecturing in both the UK and the US on biomechanics, I'd say that average UK audience was much more interested in the subject than the average US podiatry audience. The ability to practice biomechanics is related to how much you think about it and the amount you think about it. Even if more time is spent on biomechanics, there is the question of whether you are learning true biomechanics (forces and moments. Kinetics vs kinematics). What I learned in podiatry school was podiatric biomechanics where there was not really much mechanics. Anatomy is important and that was emphasized to some extent in podiatric biomechaincs, but there was little mechanical analysis of mechanical structures.



    I would agree with you that having a change in the orthotic shape by correcting the forefoot to rearfoot relationship is an important variable in making an orthotic. However, I don't think measurement of forefoot to rearfoot relationship in neutral position is a good way to choose the amount of intrinsic post that you have in your orthotic. Start with the logic of you measure forefoot to rearfoot in neutral position and the foot stands pronated from that position over 95% of the time. I could go on and on about what's wrong with neutral position. I have at other times here on the arena.

    The ability to find neutral position would not be high on my criteria for evaluating someone's ability in treatment with orthosis.

    Eric
     
  21. RobinP

    RobinP Well-Known Member

    Robert,

    With respect, from the reading I have done previously, the DPM qualification is a pretty comprehensive one and I wouldn't deign to challenge your knowledge on all things foot and ankle related. However, I do know a bit about biomechanics and if it is your contention that an OTC device works by soothing the plantar skin nerves then there is probably little point in continuing this discussion much further.

    I think you will find that current thinking with regards to orthosis therapy sits a long way from your opinions. I would concur with what Eric has just said in as much as finding a "neutral"position and capturing the rearfoot to forefoot relationship for that neutral position would not be high on my list of priorities when assessing a patient with regards to their orthotic requirements. In fact, I'd probably generally be a bit less polite.

    Everyone is entitled to their opinions. However, this is the type of opinion that will lose a person some credibility

    if followed up by this statement

    Regards,

    Robin
     
  22. Hey Robert.

    I'd agree with my rt hon colleagues views already expressed. Because I have a heart of gold I'll also attempt to explain exactly why I think so.

    Patients in pain or podiatrists who use pre fabs do not do so out of a sense of whimsy or fun.

    May, not will. 1

    To use your words, this is "without foundation". the Landorf Study 1 makes no distinction between the scale of the "concern". Also for "feel" better one could read "get" better as per the same study.

    1. How does one determine if a patholgy is "caused by a forefoot / rearfoot" misalignment? Are you suggesting that ALL of the pre fab successes in the landorf study had perfect RF/FF alignment (whatever that is). Thats what you're saying, is that what you mean?!

    2. What is the "correct" forefoot / rearfoot alignment? Is it perpendicular to the rearfoot per Root, or is it "normal" as in average at 8 degrees inverted per Garbalosa 2

    3. How does one measure it when the rearfoot bisection is so horribly inaccurate (6 degrees +/- 3)


    Pure supposition and inaccurate. Any shaped insole, unless made of shaving foam, will alter forces. And what exactly is to "sooth planter skin nerves"? Orthotics change forces depending on their shape, Load deformation characteristics and friction co-efficient. Whether they are pre fab or cast makes zero difference.

    Any orthotic or insole which changes forces in the foot (vis, pretty much all of them) will also change forces in the ankle. Since out "treatment" is based around the concept of changing forces, it follows that any such orthotic will treat the ankle. It is fallacious to infer that one type of orthoses will not treat the ankle.

    Re "in the US" I'm unaware that the laws of physics change based on what country you're in so I suspect this principle is global.

    And yet, some do.

    True. I don't know the fine detail of American training, but I suspect it varies in quality and scope. You have your Kevin Kirby's and Eric Fuller's, but you also gave the world Brian Rothbart and Ed Butterworth. As such I'm unconvinced that the line between good biomechanist and bad biomechanist is based on the country one trained in. Also, as Eric rightly points out

    There is that correct alignment again. I refer you to my earlier questions. Also while we're on the subject, we have research which shows 16 degrees of intracaster variability of forefoot to rearfoot angle 4. That being so, how "properly" can these be corrected with an insole.

    Oh and yet another thing. If you are trying to "align forefoot to rearfoot" you need to know how much you've inverted the rearfoot. How much medial posting does it take to invert a heel by 5 degrees so its vertical? The answer is NOT 5 degrees. So does ANY orthoses align the forefoot to rearfoot?

    We have other research showing OUR ability to reproduce neutral is a bit shaky as well 5. So I'm unconvinced that we can boast too much about that.


    Wow. All the time? Thats impressive. Also a boast with no shred of evidence.

    Never mind. I'm sure the Podiatrist up the street is able to explain why your devices failed. Because we tend to see other peoples failiures rather than our own don't we. Anyone who claims a 100% success rate either has a very unconventional definition of success or is kidding themselves.

    I agree with Robin when he says
    The whole idea of an orthotic aligning RF to FF is a bit last century IMO. Align to what angle? At what point during gait? All the evidence tells us that the angle we put on our orthotic has a wildly inconsistant effect on the angle in the foot, even if we looked at a single static position, which we cannot.

    I shall, however, not ascribe this disagreement to your training vs mine because you may not be representative of your background nor I mine. And thats very much the point isn't it. One cannot catagorise people that way. Your views are your views. My disagreeing with you does not lead me to state that I disagree with all US podiatrists, or to critique your training, that would be silly. By the same token, perhaps it would be wise not to lump all orthotists together based on YOUR disagreeing with a few of them.

    But then, what do I know?

    Kindest regards

    1. Landorf K B, Keenan A M, Effectiveness of Different Types of Foot Orthoses for the Treatment of Plantar Fasciitis Journal of the American Podiatric Medical Association Volume 94 Number 6 542-549 2004

    2. Garbalosa JC, McClure MH, Catlin PA, Wooden M (1994) The frontal plane relationship of the forefoot to rearfoot in an asymptomatic population. J Orthop SPorts Phys Ther 20(4): 200-206.

    3. LaPointe SJ, Peebles C, Nakra A, Hillstrom H. The reliability of clinical and caliper-based calcaneal bisection measurements. JAPMA;2001;91(3)121-126

    4. Vivienne Chuter, Craig Payne, and Kathryn Miller Variability of Neutral-Position Casting of the Foot J Am Podiatr Med Assoc 2003 93: 1-5.

    5. Pierrinowski M, Smith B:proficiency of foot care specialists to place the rearfoot at subtalar neutral:JAPMA;Feb 1996;86(5) 217-223
     
  23. Ian Linane

    Ian Linane Well-Known Member

    The irony for me in all this is that it was an ORTHOTIST, long before I knew of KK's work, that

    1 opened my eyes to biomechanics better than any podiatric input I'd had
    2 taught me how to manufacture orthotic devices using material from simple felt to EVA to Poly Prop to Carbon Composites to Wet Up-Lay pure carbon fibre techniques (B****y time consuming that one).

    There again, if I'm honest, there are times when I feel I've learnt more from other disciplines about treating MSK stuff for the low limb than I have from many podiatric courses, with the exception of some course mind you.

    I raise the orthotist flag, at least the ones I know.

    probably said all the wrong things here, ah well.
     
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