Do you expect new orthoses to cause pain

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Dear all

Over the years I have fitted thousands of pairs of orthoses. Over that time it has never been my experience that they tend to hurt at first. My advise is if they cause any pain that is more than mild stop using them come back and I'll adjust them. It is seldom anyone comes back or complains of extra pain between initial fitting and 6 to 8 week review.

The reason I ask is I had a colleague visit my practice, a lovely lady by the name of Marcia. She asked the same question because she was bemused by the fact that some podiatrists she spoke to always expected their orthoses to hurt and they gave the advise that the orthoses would hurt and was an indication that they were doing their job correctly. IE they are pushing the foot into its correct position and it will take some time to get used to it.

Both Marcia and I have great sucess with our orthotic interventions but neither of us expect them to hurt more than the occasional arch irritation, which for me is a very rare event with either EVA or polyprop.

I see my orthotic designs and intervention therapy as a facillitation rather than an enforcement of function.

What do you expect?

Cheers Dave

 

In a rush ... arena'ettes crying .... will reply more fully later...

Two studies have shown that the more comfortable an orthotic is at issue, the more likely there will be a positive outcome.

 

Dave,
as a podiatrist and psychologist I am really pleased to learn that you and Maria have come up with a gentle, effective support system. In our present forms at least, we come to this life only once..... let us and our patients both enjoy quality and comfort!

 

We tell our clients that they will feel pressure from the new orthotics which will feel "weird", "Strange", "awkward" and will take a day or two to get use to but never painful, mind you we have the luxury of fitting the right shoe to them on the spot, it all helps to get that positive outcome

 

With ALL Orthoses, from issue :

#1 Orthoses must fit footwear

#2 Must be Comfortable (strange, yes, but definetely comfortable)

#3 Then will be able to assess outcome

:morning:

Cheers,

Paul Dowie

 

Dave:

This is an excellent question. Here is how I approach the question of how much discomfort the patient should have in the initial orthosis fitting appointment. I have dispensed over 15,000 pairs of orthoses over the past 25 years.

First of all, for the initial orthosis fitting appointment, my assistant has given the patient the attached handout to read before I enter the room and has been asked to read the handout before I enter the room. Once I am in the room with the patient and greet them, I carefully place the orthoses up to the plantar aspect of each foot while the foot is held in the negative casting position to make sure that both orthoses are fitting correctly. Then I will fit the orthoses into the shoes, being careful to make certain that they are fitting properly with no abnormal anterior displacement, abnormal frontal plane angulation or abnormal lifting of the anterior edge away from the insole of the shoe.

Next, I will have the patients put the shoe and orthoses on and I will observe them walk up and down my office hallway. During this time I am making sure their gait has no obvious abnormality and appears to be improved with the orthoses and that their walking speed is normal.

After about a minute of them walking up and down my hallway, I ask them: "How do the orthotics feel? Do you feel any sharp edges or irritation from the orthotics? If they don't have pain they may otherwise answer that the orthoses feel "different", "weird", "odd" or "wonderful" but could also answer "like I have large rock in my shoe". I pay close attention not only to their gait at this time but also to their facial expression to see if they look worried, happy, or seem stressed in any way. I don't want patients to hide their initial input of orthosis sensation to me so I may also say to them "don't worry, I don't mind if you tell me they feel uncomfortable initially since this is not an uncommon feeling with new orthotics. I want to know honestly know how they feel to you."

If there is any feeling of "jabbing", "sharp pain", or "large rock in arch" sensation from the patient, or if their gait mechanics is abnormally slow or antalgic, I will then evaluate the orthoses again and possibly make an adjustment to the orthoses on the dispensing visit. I do an orthosis adjustment on the initial orthosis dispensing appointment in only about 5-10% of the orthoses I dispense.

Otherwise, if the sensation expressed by the patient is "pressure but no pain", "full feeling in arch", "odd", "weird, "different" or a more positive expression as "feet feel better already", I will not adjust the orthoses on the first visit. Patients that have previously worn over-the-counter orthoses generally have an easier time becoming adjusted to orthoses than those who have never worn any form of orthoses.

I do not agree that orthoses should be painful from the onset. The clinician that thinks it is acceptable or normal for orthoses to be painful at the initial orthosis dispensing appointment are likely making poor orthoses and have a poor understanding of how well-made foot orthoses should feel. However, I do expect many patients to express an opinion that the orthoses may feel "odd", weird" or "different" on the initial fitting appointment since the plantar pressures I am exerting on their foot with their new custom foot orthoses should be very different than anything they have likely experienced before. Reassuring the patient that the different sensations they are feeling with new orthoses is totally normal and that these sensations should resolve over the next few days to few weeks helps the patient to realize what they should expect, or not expect, during the orthosis break-in period.

Understanding how to properly dispense orthoses is just as important as knowing how to properly cast and prescribe orthoses. Any weak link in the evaluation, casting, prescription, fabrication, shoe fitting, and shoe prescription chain of events that goes into making optimum custom foot orthoses will greatly decrease the likelihood that the patient will derive optimum therapeutic benefit from their custom foot orthoses.

Hope this helps.

 

Spot on :drinks
I am sure we have had patients come in for a second opinion with orthoses that have 'taken about 3 months to get used to' having been told on each review that they need more time...:craig:
One difficulty with polyprop orthos is that often patients expect them to feel hard and therefore feel that if they are uncomfortable it is just normal, rather than a sign they may need some adjustment.

 

If the kids have stopped crying, could you possibly post these references? I think they are from Nigg's group are they not?

 

G'day David,

I'm of the camp that orthoses should feel strange, but not uncomfortable. My issue process is very similar to that of Kevin's, however I do not have a hand out, but what a great idea! One thing I have learned in my experience of my own person orthoses, and I've had many a pair (i've got 'great' feet cough cough), is that one device usually feels 'wrong' for about the first 6 weeks. The problem is, one day it's the left and the right is comfortable, and then the next its the right with the left comfortable. I put it down to this: Orthoses are orthopaedic devices, they are attempting to alter foot punction by offloading, reducing tissue stress, alter alignments, redistributing force, (and every other concieveable defination of how orthoses are supposed to work) and as a result, the body will take time to get used to them, adjust to them, and become 100% comfortable with them. Orthoses should feel strange as a foot adjusts to them, but I believe that they shouldn't be uncomfortable. Anecdotally, I've always found that the best results I've found has been with devices that were comfortable immediately. I often tell my patients that they are like a pair of glasses for the feet, helps most understand how important the new devices are to improving their foot problems

Cheers!