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.
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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?
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The problem becomes if you on´t get what you want and then you need to talk to the guy making them -
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. ;) -
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 -
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 -
Ok, DIFFERENT dogma.
Happy with that? -
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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.
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
RobinLast edited: Jul 11, 2011 -
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] -
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 -
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I've just re read the part of the post that says
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. -
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So basically your whiteboard is your prescription form- just out of interest how big is it? ;)
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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.
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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? -
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 ? -
The ability to find neutral position would not be high on my criteria for evaluating someone's ability in treatment with orthosis.
Eric -
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
Robin -
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.
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)
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.
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?
I agree with Robin when he says
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 -
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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