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Validity of temporary orthoses V's custom

Discussion in 'Biomechanics, Sports and Foot orthoses' started by David Smith, Jul 26, 2007.

  1. David Smith

    David Smith Well-Known Member

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    Dear all

    Re thread Researcher V’s Clinician
    Part of the thread regards the validity of using temp orthoses before bespoke ones.
    I have found it interesting and useful as a reflective study and would like to continue to discuss the validity of using temporary chairside or OTC orthoses as a precursor or assist to the decision making process before electing to use bespoke orthoses or not.
    I am of the opinion that it is generally a waste of time and at worst inhibits or confounds the decision making process and reduces patient confidence. This does not preclude the use of chairside or OTC orthoses when the clinician thinks that this is the required and best intervention for that particular patient / customer, which may also include considerations other than clinical such as cost and affordability.
    From thread Researcher V’s Clinician - Shane Toohey wrote

    My suggestion is to treat every person as SINGLE CASE STUDY.I do this by using chairside orthoses (full length pre made moulded insoles with various wedges or buildups attached according to what is seen as likely to be helpful in the examination) and used for a trial period. I will not make custom made orthoses if I have not made a significant reduction in symptoms over a few weeks with this method. This gives strong prescribing clues both to magnitude and direction of the interventions. Sometimes the chairside devices remain as the sole intervention and sometimes they become just a diagnostic tool and a spare insole. If the chairside device did not help it may be further modified but nevertheless it needs to be significantly helpful before taking the therapy any further.

    If for example a large medial wedge was used in the rearfoot the there are different ways of achieving that with a prescription according to the practitioners skills (and we know how you would do it!)

    Kevin Kirby wrote
    Custom foot orthoses must be specifically designed to reduce the magnitudes of abnormal external and internal forces and moments acting on and within the foot and lower extremity in order for the foot orthoses to have maximum therapeutic benefit. The Tissue Stress Approach that Eric Fuller and I will be lecturing on at Biomechanics Summer School 2007 in Oxfordshire,England http://www.rxlabs.com/summer_school.asp in a few weeks (along with Sophie Cox, Emma Cowley and Diane Nichol) involves determining the anatomical structure that is injured, determining what type of abnormal force/moment is producing the abnormal stress/pressure on the tissue that is symptomatic, and, by using modelling techniques, determining how a foot orthosis must specifically be designed to apply the necessary forces to the plantar foot to optimize the healing of the injured structure. It is really as simple as that. This method requires no pre-fab or adjusted temporary orthoses beforehand and produces very predictable clinical results.

    Dave Smith replies to Shane
    While I respect your treatment protocol I cannot agree with it.
    If a patient who had a severely arthtitic knee was told by his orthopaedic consultant that, he was going to treat him as a single case study and said, "you might need a new knee joint but first I'm just going to tape this stick to your leg and see how you get on. If it does not improve your knee significantly then I will not be fitting a knee joint as obviously it would be a waste of time".
    How ridiculous would that be. Is this not the same as your protocol? You are going to use an inferior intervention to trial a superior intervention and make an invalid and unreliable extrapolation of data as a conclusion to your decision making process??? And if you customise a preformed orthosis so that it works then this is a custom orthotic (it is not bespoke tho) but a cheap one that won't last long. This logic is flawed. Use your best option first.

    Toeslayer wrote
    And Dave smith replied (Italics)
    >If a patient who had a severely arthtitic knee was told by his orthopaedic consultant that, he was going to treat him as a single case study and said.......................
    I think it is the principal of a working diagnosis (clinical hypothesis) followed by evaluation of feedback (cue acquisition) that forms the basis of a single case control, here. Taking your example the orthopaedic consultant is only accessed after all other avenues have been explored with the clinical options more clearly confined to their expertise. This scenario may not be so clear in general podiatry.

    Toeslayer, you may be right but how does it help the podiatrist or the patient to prescribe a device that only improves things a bit, with the intention of fitting something else, at a later date, that works better.

    >You are going to use an inferior intervention to trial a superior intervention and make an invalid and unreliable extrapolation of data as a conclusion to your decision making process???

    Bearing in mind clients rarely present without co-moribund complications which are uncomplicated a thorough history of the complaint is as revealing as detailed biophysical data.

    Without Co-moribund complications which are uncomplicated? Moribund - meaning, in a dying condition. I don't understand this half of the paragraph, can you explain.

    "a thorough history of the complaint is as revealing as detailed biophysical data."

    Yes agreed

    Podiatric biomechanics swank aside, Newton's Rules determine you can either lift, tilt or wedge bits of the foot and in truth it matters not a jot what you do it with (from the armoury of podiatric materials),

    Yes it does! Material properties are a significant consideration in the prescription and construction of effective orthoses.

    if as a result, painful symptoms associated with underlying pathologies subside then that is a very valuable clue to the clinician and justification to extrapolate.

    But what if the symptoms do not subside, what can you conclude from that scenario? Orthotics won't work or only the temp orthoses used don't work.
    What then, make another temp pair with a different prescription and hope they do the job. And if they do give a clue then why not just use a bespoke orthosis first of all and save the in between bit of waffle. It's just a waste of time and effort. And IMO only suitable for the clinician that is not sure about what they are going to achieve with a certain prescription and/or a particular patient.

    To do otherwise might constitute experimentation without informed consent.

    Surely faffing around with trial temp orthoses is experimentation. Am I misunderstanding you?

    A "Try this and see how you go," approach in the full knowledge a practitioner cannot predict with any confidence the likely outcomes (good or bad) could be construed as unethical. Since there are no ethics in podiatry then this might be seen as bad practice.

    Unethical? it could be, I agree, but I'm not sure which side you are arguing for now. I am pretty confident I can predict the outcome of most of my prescriptions I.E. patient will get better.

    >And if you customise a preformed orthosis so that it works then this is a custom orthotic (it is not bespoke tho) but a cheap one that won't last long.

    Semantically 'custom' and 'bespoke' mean the same thing. However you do bring up an interesting point with the phrase "won't last long".

    By the dictionary you are correct. To me custom or customised means to alter a generic to the customers requirements. Bespoke means to make an original to the customers requirements. If you customise an OTC product so that it is the same in every way as a bespoke product then you can no longer claim that you have fitted an OTC product. And the argument is moot.

    To be analytical for a moment (no criticism intended to the author), to put a value on the device's longevity would raise several questions.

    Is the condition life long and therefore requires life long care?

    Is the condition transient (will respond to short term intervention) and if so what purpose does the foot orthosis serve after symptoms subside?

    The condition may be transient but most often the biomechanical aetiology is permanent. Therefore lifelong use is useful.

    Does a quality product equate to quality care ?
    Will the client receive a rebate if the condition does not improve?

    I believe a quality product will be better in the long term and enhance the patients perception that they are getting the best care and so will expect the best outcome therefore they will get it. Rebates are a comercial consideration.

    If you fit two products that give the same outcome but one lasts longer, looks better and needs less maintanence, which is the better.

    Thanks all, Dave Smith
    Last edited by a moderator: Jul 27, 2007
  2. Re: Validity of temporary orthoses V's bespoke

    We tryed using modified pre fabs / chairsides as a first line treatment a while beck.

    We stopped because they inevitably led to the construction of a bespoke device.

    Option one - Chairside worked - needed something that would last. Made a bespoke

    Option two - Chairside did not work - Tried a bespoke to see if that would work. And more often than not it did!

    That said i can see chairsides having great value in the private sector to convince a patient that shelling out £300 for bespoke devices is worthwhile.

    I recently costed making insoles in our NHS lab and found that it cost around between £10 and £20 to make an average pair of EVA 's or polyprop shells. Somewhat less to make a pair of simples. The appointment to make a prefab cost about £5 and the pre fabs themselves cost a few more quid depending on what flavour we used.

    Financially it just was not worth it.


  3. David Smith

    David Smith Well-Known Member

    Re: Validity of temporary orthoses V's bespoke


    Exactly my point.

    I have found that the opposite is true. If the Temps work then the customer wants to keep them and is sceptical that bespoke will be any better for the extra cost. If they do not work then they lose confidence in any orthotic intervention and do not want to pay out for more expensive bespoke orthoses. When they keep the temp orthoses they expect them to be maintained free of charge when they fall apart or the stick on bit move around. BTW I charge £180 - £260 for bespoke orthoses. To make them myself in milled EVA costs £56 and polyprop shells from a lab cost about £120
    inc covers, PoP (not lemonade or iron bru) and P&P and other consumables.

    OOH! that's very cheap, do you only earn 75p an hour? Can you make mine please ;)
  4. Re: Validity of temporary orthoses V's bespoke

    I would'nt have thought of that!! :rolleyes: Patients. Gotta love em.

    Thats the NHS for you. 75p an hour, half a pickled egg on fridays and the right to visit trust HQ for a staff meeting every month so long as we don't touch anything or speak to anyone. They have carpets and soft loo roll and everything! I'm now to the point where i can do 20 plus pairs from rough casts to finished insoles in a day. But i've visited a commercial lab and you'd better beleive they do it quicker! If only i had room for a second vacuum former or a grown up oven! Maybe if i got rid of some materials :rolleyes: ;) Or not.

  5. admin

    admin Administrator Staff Member

    I have changed the title of the thread from 'bespoke' to 'customs', as 'bespoke' is pretty much a UK only term and would not be widely known elsewhere.
  6. Admin2

    Admin2 Administrator Staff Member

  7. Scorpio622

    Scorpio622 Active Member

    No need to do this in the age of the internet. I looked the term up and there is actually a Wiki on it.

    I agree with the aforementioned regarding the prefabs.

    The best litmus test in my opinion is a low dye taping. It is something that patients do no wish to carry on forever, but if effective it indicates a biomechanical cause of pain/dysfxn and segways nicely into the customs (i.e. "bespokes")
  8. I don't think that a clinician should use or needs to use low-Dye strapping to know whether symptoms are of mechanical origin in a patient. Careful history taking is actually an inexpensive, little recognized but very effective method for determining whether a symptom has a mechanical etiology or not. Symptoms of the feet and lower extremities caused by the mechanical interaction of the foot with the ground during weightbearing activities will tend to have one or more of the following characteristics:

    1. Pain or symptoms increase with increased duration or increased intensity of weightbearing activity (except for phenomenon of post-static dyskinesthia).

    2. Pain or symptoms decrease with increased duration of non-weightbearing activities (i.e. sitting, lying).

    One specific problem of using low-Dye strapping to determine whether a symptom is of mechanical origin or not is that low-Dye strapping may actually be much more effective at relieving certain types of mechanical pathologies in the feet than will foot orthoses and low-Dye strapping may also be much less effective at relieving symptoms than foot orthoses in other types of pathologies. Low-dye strapping works mechanically by applying tensile forces to the plantar foot to increase rearfoot dorsiflexion moments and increase forefoot plantarflexion moments. However, foot orthoses apply compression forces to the plantar foot to increase rearfoot dorsiflexion moments and increase forefoot plantarflexion moments. Since low-Dye strapping works by a very different mechanism from foot orthoses in altering the internal moments acting across the joints of the foot, one should therefore not assume (contrary to popular podiatric myth) that low-Dye strapping is a good "test-method" of determining the potential therapeutic effectiveness of foot orthoses.

    If the clinician is unsure as to whether the symptoms are of mechanical origin or not, the use of over-the-counter foot orthoses that have been specifically modified for the patient's mechanical symptoms are a much better "test" of the whether custom foot orthoses will work or not for the patient than using low-Dye strapping. However, the best "test" to see whether custom foot orthoses will be effective at relieving the patient's symptoms is to make custom foot orthoses from a three-dimensional model of the patient's foot that have been specifically modified to reduce the abnormal external and/or internal forces acting on and within the foot and lower extremity that are causing the patient's symptoms. These tissue stress-modelling concepts will be explored further in the lectures by Eric Fuller and myself next weekend in the UK at Biomechanics Summer School 2007.
  9. Scorpio622

    Scorpio622 Active Member

    Some cases of neurogenic claudication, vascular claudication, early sympathetically mediated syndromes, radiculopathy, nerve entrapments, metabolic tendonopathies, stress fractures/reactions, and occult fractures from remote injuries may present with weightbearing increase of pain. Most cases are just like you state, but some are not.

    My feeling about the low-dye that has been worn for over 2 hours is that it blocks endrange pronation and thereby decreases the (pathological ?)tissue forces that would normally occur with this. Perhaps this is an oversimplification, but I have found that those who do well with the lowdye do well with orthoses, and those that don't should undergo further exam for the aforementioned conditions as well as others. This approach has served me well for many years, but I am open to change.......
  10. Atlas

    Atlas Well-Known Member

    Disagree. What is wrong with the musculo-skeletal clinician having this in their knapsack to use when needed? Relying 100% on careful history taking infers that every one of our patients is an excellent historian. Compared to a custom-made orthotic, strapping is inexpensive and has some similar impact on the foot and lower-limb.

    Not all practitioners dispensing or thinking-about-dispensing orthotics are as experienced and bio-physics knowledgable Kevin. There is a bigger picture here. There are some podiatrists out there absolutely petrified of 'biomechanics and orthotics'. In my opinion, a pedantic fascination with terminology and a overcomplication of the whole thing we are discussing are partly to blame.

    There are others that are prescribing unaccountable rubbish. There are others that are occasionally lucky. There are many others doing a decent job of course. Many of these people could do no worse than follow the advice of Scorpio and Toohey and first prove to themselves and their patients that changing foot mechanics has a beneficial effect on their lower-limb complaint.

    Establishing mechanical versus non-mechanical pain is only one issue. What about establishing cause and effect? Is my patients knee pain in anyway due to pathomechancial issues of the foot? Will changing the these issues assist in resolving my patients' knee pain? Are we going to ask advise someone on the poverty-line to spend a month's welfare on our hunch?

    What about exercise induced compartment syndrome? The patient has little to lose by spending less than 5% of an orthotic cost in establishing whether 'changing the foot' will change symptoms.

    Agree Kevin. Well done.

    What ever they apply, the effect on moments here, as you describe, are the same. Lets not kid ourselves. Strapping CAN (not always, not never) have a similar effect to orthotic devices.

    And I would question whether increasing rearfoot DF moments and forefoot PF moments, wouldn't increase tensile forces in the dorsal aspect of the peak of the arch anyway.

    One shouldn't assume that is is a bad one either. You are correct that the mechanism is different, and the correlation is not 1:1, but its not far away. In fact, those believing in this 'popular podiatric myth' are better off, as are their patients, for believing so.

    Kevin, what about those feet at the ends of the bell shaped curve in relation to width and length? You know as well as I do, that OTC foot orthoses do not cater at all for the ultra narrow foot for instance. OTC orthoses manufacturers would not make sufficient profit if they made devices of all shapes and sizes.

    A. Cost-effectiveness
    B. Kevin, a "test" should be quick and inexpensive. I dated my wife before marrying her, not vice-versa.

    We owe it to ourselves, our patients, and the profession at large, to facilitate grey thinking, not black and white. If you are going to be black and white, and have the power and authority that you do, you better be correct. There are huge numbers of confused foot/ankle foot clinicians nervous about dispensing orthotics. There are huge numbers of custom-made-devices that are being issued at huge cost, that fail miserably. And I have probably dispensed one or two of these...at least.

    Taping is an inexpensive, nothing-to-lose, everything-to-gain tool that the lower-limb musculo-skeletal clinician has at his/her disposal to determine causality (for students and us mortals); improve signs and symptoms for short-term or longer; to prove to a pessimistic patient (who reads podiatry arena and concludes that customs are no better than pre-fabs); to prove to insurance companies; to prove to yourself; to enhance prescription (if low-dye taping works, I doubt you will need an inverted rearfoot controlling device for instance).


    Shane Toohey and Scorpio are well on the right track, and podiatric students should be exposed to their thinking IMO.
  11. Ron:

    Thanks for responding. I'm sitting here at Sacramento International Airport waiting for my flight to leave to San Francisco then on to Heathrow Airport in London. I have a few minutes to respond to your posting.


    When did I say anything about "relying 100% on careful history taking"? What I did say was "I don't think that a clinician should use or needs to use low-Dye strapping to know whether symptoms are of mechanical origin in a patient. Careful history taking is actually an inexpensive, little recognized but very effective method for determining whether a symptom has a mechanical etiology or not."

    If the clinician wants to use a strapping to help him or her determine whether the symptom is of mechanical etiology or not, then that is their choice. But why not use history-taking to better understand the true nature of the injury before one starts applying tape to the foot? The best clinicians are often the best history-takers.

    By the way, Ron, what do you charge a patient to apply a low-Dye strapping to both of their feet? What is your definition of "inexpensive"? Is that your definition or the patient's definition?

    There are many podiatrists who just don't care at all about biomechanics...especially here in the US where they would rather fuse a painful joint than make an orthosis to try to relieve the pain within the joint. :eek: I don't think that I have ever had someone describe my postings as consisting of "a pedantic fascination with terminology and a overcomplication of the whole thing". Dr. Mert Root often complained about imprecise terminology in podiatry and that imprecise terminology was responsible for much of the confusion when communicating biomechanics to podiatrists and other clinicians. Dr. Root didn't feel that his ideas were overly complicated. A lack of comprehension of basic mechanical terminology can be viewed either two ways: (1) an ignorance on the part of the clinician to the point that they feel the subject is "overcomplicated", or (2) an understanding by someone who has shown enough interest to learn basic mechanical terminology so that they often wonder why others rhat have their same degree and training can't see how easy things become once basic mechanics terminology is understood.

    In regards to your complaints about being pedantic, maybe we should go back to the terms "hyperpronation", "hypermobility" and "1st, 2nd and 3rd degree flatfoot"?
    That would be real academic progress. :cool:

    Certainly, if a clinician feels comfortable with either means, putting on a low-Dye strapping or dispensing an over-the-counter insole to a patient, then there is nothing wrong with either. It is the clinician's choice. However, my points about low-Dye strapping not being a good test for whether a patient will respond or not respond to orthosis therapy are still biomechanically valid. I think over-the-counter insoles that are specifically modified offer a much better, biomechanically-valid test of the potential therapeutic benefits of foot orthoses than do a low-Dye strapping.

    Are these best decided by having the patient spend their "welfare" money on a low-Dye strapping that lasts 1-2 days or an over-the-counter modified orthosis that may last 3-4 months?? Which is the most cost efficient for the patient over a three month period? I would bet that over-the-counter modified foot orthoses are much more cost-efficient when estimated over a period of one month or more for most podiatric patients.

    Chronic exertional compartment syndrome (CECS)http://www.podiatrynetwork.com/print.cfm?id=159 often does not respond to either strapping, over-the-counter or custom-molded foot orthoses. However, considering that the next step after conservative care for CECS may be surgery to release the compartment, maybe you should consider that most patients may be willing to spend their money on the therapy that has the best chance of preventing surgery than wasting their money on a "test" that may or may not work and would still leave them with the remaining two options of (1) either trying custom-molded foot orthoses or (2) surgery! Again, which method is the most cost-efficient, Ron??
  12. Stanley

    Stanley Well-Known Member

    I would like to add my thoughts to this discussion.

    I agree with Dave.

    There are times that a condition is due to abuse/overuse and not purely biomechanical (in runners). Taping a foot is one way to simply find out. If the foot taping alleviates the pain, and the pain does not return in a week, then the pathology is abuse/overuse. If a percentage of the pain returns, then further taping is required. If the pain is alleviated with the taping, and when the taping stretches or comes off the pain returns, then custom orthoses are indicated.

    From this we can determine that temporaries do not help us in making a determination of the necessity of custom orthoses.

    This is what I found in practice.

    The reason to do either temporary orthoses or taping is primarily to convince the patient they are required, and rarely the doctor.

    This is because foot tapings change position. If orthoses do not change position, then they won't be as effective.

    The low Dye is not always the best foot taping, as it only effects the medial side of the foot and is primarily a midfoot taping. Depending on the pathology and what structures you want to change the force on, different foot tapings are utilized.

    There are variables to this that will result in different answers. Depending on the patient's insurance coverage, and how long it takes for the lab to deliver the orthoses will determine the answer. If it takes 3 months to get the orthoses, then the temporary orthoses (assuming it helps) is more cost effective. If it takes one to two weeks to get the orthosis, then taping is more cost effective. Some insurance plans in the states, will cover temporary orthoses and/or custom orthoses. There is one that will cover the custom, but not if you make the temporary. Dealing with insurance companies are much more complicated than dealing with midtarsal joint mechanics. :eek:
    Then there is the variable of the socio economic status of the patient. If they are poor working class, then they will not be able to pay for anything the insurance doesn't cover. If they come from a higher socio economic status then out of pocket expenses are less important.
  13. What does the published research say about the kinetic/ kinematic effects of low-Dye taping?

    The only study I can recount from memory was by Harradine et al. in The Foot in which (I think) they showed that after a few minutes it doesn't do a great deal at all. Could be wrong, just what I seem to remember.

    Patients like it though and I guess that's what counts.
  14. Atlas

    Atlas Well-Known Member

    That is what the published research says, I don't doubt it. In my physio days, the physio research basically said ' 20 minutes then its psychological....'.

    But in the clinical world I knew it was bollocks. If I can (for example) apply an anti-extension strapping to the elbow and prevent it from straightening (40 degrees+) for 4-5 days, then I must be a very powerful psychologist.

    This is one example of why I have never taken too much from the 'latest research paper', irrespective of its methodology. If it doesn't tick boxes clinically and common-sense wise, well it might as well be the News of the World.

  15. David Smith

    David Smith Well-Known Member

    Hi all

    First off, as for precise terminology, which requires and probably had a seperate discussion, in the early days of reading Kevins predeliction for precise descriptive terminology I too thought him to be a little pedantic. I have since changed from that opinion and have come to realise that vauge, traditional or colloquial terminology can be ambiguous. Ambiguity can be convenient for the clinician when the precise nature of the mechanism of an injury or the subsequent intervention in not precisely understood and therefore a general coverall term can be both accurate and satisfying to both medic and patient.

    This statement itself shows the need for precise terminology to be both used and understood. While a term can be accurate it may not be precise. To use the term "internal rotation" is accurate but not precises since there is is no quantification of magnitude or defiition of which axis the percieved motion is about. One of the worst offenders is "Hypermobile" again while it is somewhat accurate it is not precise and gives no idea of quality of RoM or the reason for the lack of stiffness or unusualy large Range of Motion. Even as a general term it has different meanings for different diciplines.

    For the engineering minded person, accuracy and precision are very important as without it confounding data lead to poor conclusions and repeatability.

    This is the same in communication, especially of the written word where there are no other communicative expressions to extrapolate the true meaning of a persons words. We communicate on this site by the written word as do we by our research papers. Poor, imprecise terminology leads to poor imprecice communication and reduces the ability of the reader to make useful conclusions about the information conveyed.

    Therefore, while the ambiguous teminology has been useful in the past, I believe precise terminology is more useful for both clinician and biomechanical engineer when they wish to communicate well in the future.

    Strapping :-
    I find rigid strapping IE figure of eight passing around the heel and crossing under the plantar midfoot is very useful where the patient has plantar fasciitis and is used in the iterim period between assessment and orthotic fitting. This is from 2days to two weeks usually. This would apply equaly to tape used to add supination moments and reduce Post Tib trauma.

    I agree with Stanley that overuse injuries are sometimes transient and a temporary intervention will suffice. The same would apply to acute traumatic injuries such as ankle sprain. However am I right in saying that all injuries aetiogical of biomechanical dysfunction are in fact overuse injuries in essence. Therefore since the biomechanical dysfunction is likely to be permanent then a permanent intervention would be useful.


    Cheers Dave
  16. Stanley

    Stanley Well-Known Member

    This is a plantar figure of eight strap, :cool: and it plantarflexes abducts the first metatarsal cuneiform joint, and plantarflexes abducts the calcaneal cuboid joint and cuboid fifth metatarsal joint.

    Dave, there is an element of abuse and an element of biomechanical dysfunction in any injury.
    As an engineer, you know better than I, that a biomechanical injury is related to force times time, and the ability of a part to handle the workload. :eek:
    Force is related to the degree of biomechanical dysfunction, Time is related to the overuse of the part, and then you have to subtract the adaptation ability of the individual. The question is how do we determine abuse. For instance, in running, there are some simple rules of training that shouldn’t be broken. For instance: 1. Do not increase mileage by 5-10% per week (this allows for normal adaptation of the individual), 2. The longest run of the week shouldn’t be more than twice the average daily mileage. (the maximum a runner can handle on a regular basis-they can handle three times the average daily mileage {at most once a month}, and this is called the crash point) or 3. The number of miles raced should equal the number of easy days following the race. {this allows for the time to adapt}. Also you have to remember that the adaptation ability is hyperbolic in function, it can only adapt to a genetic limit. For other activities this is not as clear.
    Dave, in theory you are correct, but what happens if you have a patient that pushes the limit? You will find yourself treating one problem, and then another. I had three crazy runners who ran together. I would fix one, and the next week the next one would come in. I would fix this one, and the next week the third would come in. I would fix this one, and the next week the first would come in again. This happened all summer. :eek:

    What about the patient that increased his mileage by 25% each week? What if he is taped to get through the crisis, and then he increases his mileage sensibly? Does he need orthoses? :confused:

    For most people what you are saying is correct. The orthoses give the patient some insurance that they can go a little extra without breaking down. Just be mindful of the exceptions. :)

    Best regards,

  17. CraigT

    CraigT Well-Known Member

    I wholeheartedly agree!
    I use an OTC orthosis if the apparent problem is minor, or, more likely, transient. It is a temporary solution for a temporary problem.
    An orthosis is a tool. It's purpose is to provide an optimal condition for the individual to be able to function. Of course, this is often in conjunction with other modalities such as stretching, core strengthening, manual therapies etc... and may not be able to achieve it's desired function without these.
    When a patient presents for an assessment of a problem, I will endeavour to give them the best solution. As a Podiatrist, I see my role as an expert in assessing how the individual foot is functioning and then managing to optimise this. This may go beyond the actual problem that the individual is presenting for-
    eg: If someone presents with plantar fasciitis, but also has shin, anterior knee and lower back problems, do we only concern ourselves with the plantar fasciitis? I would suggest there is probably a biomechanical cause, and this is what we should be treating (of course there are other components to the treatment as well). Plantar fasciitis is one condition that is notoriously fickle in that is may still persist with all our best efforts- If you manage the biomechanics, you may still have PF symptoms, but you would expect improvement in other areas. I have had patients such as these where they are grateful for what I have done and report how much better they feel... but still have PF!! If we only do enough to manage the PF, you may not see the benefits elsewhere.
    I think we should always be trying to give the best treatment... and this is a very individual thing which you can best achieve with a custom made orthosis.
    I await the roasting!
  18. David Smith

    David Smith Well-Known Member


    No disagreement from me Craig, I have to say though that I tend to have a very holistic approach to my treatment regime nowadays and (touch wood) it is a long time since I had a PF case (or any other) that didn't get better.

    (My secret is I never stay in one place long enough for them to catch me and complain :eek: ;) )

    Get back to you soon Dave Smith

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