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When Should Orthotics be Reviewed/ Replaced

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Mark Egan, Mar 9, 2006.

  1. Mark Egan

    Mark Egan Active Member

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    Hi All,

    Firstly sorry if this has already been discussed I attempted to do a search and could find nothing.

    I have just employed a podiatrist and as such I have had to start thinking a lot more about how and why I do things in the practice. One of the things they came up was the question of reviewing orthotics and replacing them. In the limited time I have been a podiatrist, working in private practice, as well as the information I picked up from tutors at Uni I have followed the following format re. orthotics -

    Review letters sent to patients 12 months following the last review. The letter explains that their orthotics need to be reviewed to ensure control is maintained.

    Review letters sent 18 months from last review explaining that the casts for their orthotics will be destroyed (the lab I use holds the casts for 2 years) and if they wish to get another set prior to this.

    Generally I tell patients that they should have a replacement set of devices every 12 months, or modifications done to the existing ones. I also tell patients that the casts of their feet need to be redone every 2-3 years as the foot has changed.

    I appreciate that many will have very definate answers/thoughts as to these statements and there is probably no correct answer. I also acknowledge that there are many variables not discussed i.e. kids growing and progressions of disease states eg. RA. I simply wish to know what others are doing and perhaps a justification (brief) as to why they do what they do.

  2. Craig Payne

    Craig Payne Moderator

    The $64 000 question and it would make a great research project.

    There are some patients who get an immediate return of symptoms the minute the foot orthoses wears down the slightest amount and need to have then adjusted or replaced and then there are those patients who clinically respond to the crappiest prefab and after x time stop wearing them and never get a return of symptoms and do not need them modified or replaced.

    I just do not have the slightest idea how to tell them apart in advance :confused:
  3. Mark Egan

    Mark Egan Active Member

    Craig as a lecturer do you tell the students in the clinic setting any thing to do with replacement remodelling or removal of orthotics? With the view of how to work in the private sector?
    As I mentioned some of my habits/ideas are based on comments from lecturers and tutors and infact I am sure it is actually written down on the information sheet given to patients when they recieve their orthotics that they need 12 month reviews. I know there are some podiatrists who attempt to have patients return every 6 months.
  4. LuckyLisfranc

    LuckyLisfranc Well-Known Member


    Who knows..? There are no "rules" about orthotic monitoring.

    I would suggest that you are looking at monitoring the "problem" rather than the "orthotic". By this I mean, eg osteoarthritis 1st MPTJ, you may wish to check progress on this condition annually, as it is degenerative. Should your orthotic management be insufficient for the condition, then this can be modified at these problem-orientated review. It just re-shifts your focus back to the condition rather than the piece of plastic.

    For me, I might review complex conditions from anywhere to weeks/months until the condition is stabilised, then look at extending the review periods out further to anually or longer once all is well. Just give them the nod to return sooner if they are suspicious of orthotic fatigue or a return of symptoms. Most people are easily educated on how to work this out.

    Its a fine line between over-servicing, and under-servicing... :eek:

  5. Donna

    Donna Active Member

    "The Clinical Guidelines for Orthotic Therapy provided by Podiatrists" from A Pod C says that review of orthotics should occur at 4 weeks and then at 12 - 24 months according to the expected "lifespan" which should be advised to the patient at dispense/prescription date...these guidelines are from May 1998. Are they due to be updated soon?
  6. Mark Egan

    Mark Egan Active Member

    Donna- thanks for the link as to being updated I am unaware of anything like this happening.

    LL - thanks for your thoughts and I agree the line is fine.
  7. admin

    admin Administrator Staff Member

  8. I don't think that there is any standard in this regard. Mert Root many times lectured that he tried to make it a point to send a note to patients after they had their orthoses for a year and when he started doing that it really increased his income with new orthoses, new patients referred by previous happy patients that had forgot about him, etc. So this is definitely an idea that may help the "bottom line" of any podiatric practice.

    However, I don't send postcards or notes to patients since I am already busy enough. I just tell patients what the average life expectancy of the components of the orthoses are (polypropylene: over 15 years; plastazote #3: 3-5 years; Spenco topcover: one year; Korex: 3-5 years) and remind them that their foot is likely to change shape slightly within 10 years that may require them to be recasted. Personally, I still wear the same polypropylene foot orthoses daily that were made for me by Precision Intricast almost 17 years ago and they still fit the positive casts like a glove (no not like O.J. Simpson's gloves!) ;)

    Who says polypropylene isn't durable? Wait! Let me answer that question, Dr. Kirby, please, please!!

    Answer: Those podiatrists that say that polypropylene isn't durable are either those podiatrists that have a financial interest in some other orthosis material or those podiatrists that don't know about the different types of polypropylene and how it is affected by the thermoforming process.

    I remember when the TL materials were being touted as being the best thing since sliced bread and graphs of polypropylene were shown that "demonstrated" how TL was a superior material to polypropylene. Once during one of these lectures I asked if the graph shown was a polypropylene sock or a polypropylene shirt? (I can be a baaaaaad body sometimes, they say.)

    My point is that polypropylene is not a proprietary material and comes in numerous formulations so it is useless to put up a graph of "polypropylene orthoses" without first describing the thickness and shape of the orthoses, how high and how long a temperature they were heated to, whether it is a stress relieved or non-stress relieved polypropylene, whether it is a copolymer, or whether it was ground out of a block or heated and pressed.
  9. Mark Egan

    Mark Egan Active Member

    Thanks for the link admin


    Firstly I am envious that you are that busy, I am in my 2nd year of running my own business and it is a never ending challenge.

    Secondly thanks for your thougths on my queries. As I stated at the start of the thread there are many variables to consider which means I may never get an answer to my queries but that was not why I asked them. I was after opinions from others who have more experience than myself as to when they repair and and replace orthotics in their practice. You raise more variables i.e. the materials used, I suppose there are many who make their own devices and therefore control the quality of the materials used and have complete control over the heating and pressing or grounding. While others depend on the labs they use to do the best?

    Personally I feel that if I have done my job well and explained everything and fix the patient they will return when problems return or other issues occur. But the business side of me says 12 month review letters and review and replace orthotics every 12 - 18 months.

    While I was a student I met an elderly gentleman who was a long term orthotics wearer (and I mean long term) when he came into the clinic he had a plastic bag filled with all the different orthotics he had been prescribed over the years. I regretted not taking photos of all of them (must have been at least 14 pairs) all different shapes and materials. I asked him which had been the best (a loaded question I know) he indicated a set of devices that were covered in leather and were made out of what looked like stainless steel. He liked them best because when thay started to wear out he simply went back to the person who made them (orthotist ?) who placed the devices on his cast and simply remoulded them by using a hammer. Perhaps all I need is a good hammer.

  10. Craig Payne

    Craig Payne Moderator

    I guess it comes down to trade-offs:

    Evidence vs consensus vs policy guidelines vs ethics vs making money
  11. Mark Egan

    Mark Egan Active Member


    It doesn't look at all complex when you put it like that.
  12. TedJed

    TedJed Active Member

    Congratulations Mark on your bold initiative to take your professional skills to the 'open market' in private practice. You are to be commended for putting your fate in your own hands without the safety net of a wage. Doing this at your stage of professional evolution is a rare step indeed, well done.

    A question I would add to your decision making thoughts is: How reliable is a patient's feedback in determining 'suspicions of orthotic fatigue or a return of symptoms'? Also, if we were to rely on '...looking at monitoring the "problem" rather than the "orthotic".' then we would have to educate our patients to an exceptionally high degree. If you, as a qualified and experienced health professional, don't have a clear guide, how the heck will a patient??

    If we consider dentistry, would you expect a dentist to say 'if you feel a problem, let me know otherwise we'll just let it go'? I don't think so. Why not? Because by the time one 'feels' pain/discomfort, a whole series of damaging steps have taken place. Is this any different from musculoskeletal conditions we treat? I think not. Therefore I believe we should have specific parameters that we check for irrespective of perceived symptoms.

    So what's a solution? Just like a dentist will check for tooth decay and gum disease, we as podiatrists can check for foot and leg related dysfunctions that may present irrespective of symptomatic presentation.

    How often? In our practice, our reviews are typically on a 6 or 12 month basis. An active athlete in a weight-bearing career will be exposed to significantly greater forces than a sedentary couch potato. Your professional assessment will decide which is more appropriate.


    Ted Jed
  13. bearfootpod

    bearfootpod Member

    Hi Mark

    I definately do not visit my dentist unless prompted by a mailout and obviously there are some Podiatry practices with well organised marketing strategies related to the return of orthotic patients - with differing intent

    Ofcourse issues such as the materials used, degree of control required, amount of use, demands of use and characteristics of the patient impact on the "functional life" of the orthotic (time period it is effective in doing the job prescribed). This life span is seperate to the issue of prescribing an effective orthotic in the first place.

    I feel the goal of patient return differs over time;

    The first period ( up to 6 weeks+) seems to be used to ensure the orthotic is doing what it was designed to do in terms of pathology/control etc and is usable by the patient for their activities/footwear etc

    During this period one of the things to be acheived is a level of patient education regarding return to you if symptoms return or new symptoms develop to allow your assessment/adjustment/replacement of the orthotics at any time in the future.

    Ongoing period;

    As highlighted by Dr Kirby materials each have differing lifespans. At the 12 month point I contact most patients and suggest a review - as at this stage most soft covers such as spenco/cashmere will most likely be on their last legs and it gives you an oppourtunity to assess the effectivness of the devices.

    After this some Podiatrists just continue to use the material with the shortest lifespan to continue to monitor the patient / orthotic over time (generally 12 months).

    Another point on pt return:

    As podiatrists still exploring our field we need to hear both the good and the bad stories from our patients to be able to develop our skills and knowledge of successful clinical outcomes of orthotics. If every patient you presribe orthotics to does return for a review then how do you know which ones didnt return because you failed to help or which ones didnt return because you sucessfully helped.


  14. Mark Egan

    Mark Egan Active Member


    Thanks for your thoughts the last comment is one that is always sticks in my mind with regards to orthotics - "the ones you never see again".

    My ego tells me "of course they are fixed!!, that's why they don't need you anymore".

    But at times of doubt I wonder?????

  15. davidh

    davidh Podiatry Arena Veteran

    I do no-charge reviews until the pt and I are happy that our agreed-uopn treatment goals have been met. This may not be complete resolution of symptoms in certain cases.

    Once the pt and I are happy I tell them to contact me when the orthoses need refurbished, or, if they break, when they break. Re-furb's at the Lab I use cost around £30, and shells are guaranteed for life.
    This seems a fair way to work, and I get a high % of repeat prescriptions, since pts don't like being without their devices for any length of time.

    I've used this system for about 10 years now - works for me!

  16. Chirotech

    Chirotech Member

    Hi Mark,

    As for me replacing orthotics varies in stages of the patients age, types of footwear, lifestyle & work activities, frequency & duration of usage, also considering other underlying mechanical or functional problems of the lower limb.

    I used variety of orthotic types (cast, heat moulded, pre-fabs), also depends of the cost, patients compliance & affordability, also the availability of the materials.

    I usually provide a review follow-up in 3 months, then 6mths-1year.

    And I would like to thank you for all your kind & very wise inputs, I shall learn from all of you. Cheers

  17. franherrero

    franherrero Welcome New Poster

    Hello everyone,

    from my practice experience:

    Over 18 years old: Patients are only asked for undergoing a first review in one year time after setting/changing the treatment. Of course, a review has to be addressed at every stage of the treatment if the patient feels uncomfortable with the orthotic, or the symptoms don't disappear. From then on, I just tell them to contact me when they need a new pair, or if the symptoms return.

    Under 18 years old: Patients are asked to review their orthotic every six months (the approximated time for the foot to grow 6mm). I think thats the best way to keep the accuracy and effectiveness of the orthotic.

    exceptions: Orthotic for Diabetic foot, rheumatoid foot, obese patients, and athletes must be reviewed every single year, regardless the age of the patient.


    Francisco J. Herrero
  18. terigreen

    terigreen Active Member

    What our office does is to send a post card to the patient every year stating that the orthotic need to be evaluated and it see if it needs an adjustment. We also tell the patient the same before they leave the office with the orthotics. About 25% of those come in for the evaluation. Of those who come in, we usually make a second pair in 50% of patients. Also, we usually treat for a different pathology in 25% of those who come in. Keep sending out those post cards!

    Teri Green
    Atlas Biomechanics
  19. Griff

    Griff Moderator

    Playing devils advocate here (and genuinely interested); What do you evaluate and how do you determine or identify if an 'adjustment' is needed?
  20. Mark:

    It's been 8 years since you started this thread. Out of interest, how do you approach your orthotic review practice now?

  21. terigreen

    terigreen Active Member

    We identify if an adjustment is needed by what the patient says. We tell the patient that an orhotic is like prescription eyeglasses for the feet. They should feel perfect. Most of the time the patient feels that they should have more support. Usually we heat up the device and raise it 1-2 mm. Most of the time they say it feels better. We evaluate the top cover, posting and general wear of the orthotics. Our practice produces between 4-5 pairs per day so we are busy keeping on top of them. Hope this helps.

    Teri Green
    Atlas Biomechanics
  22. Griff

    Griff Moderator

    Thanks for the reply Teri. So adjustments are made purely based on the patients subjective comfort and nothing else?

    Additional query: What would happen in a scenario where the pathology the devices had originally been prescribed for had completely resolved on review?
  23. Dennis Kiper

    Dennis Kiper Active Member

    My experience with bio-fluid technology is, the pt will either feel a lack of support or a return of symptoms in the first 1-2 years (I have already informed them, that they should expect one or the other or both.) . Rarely have pts returned before the first year.

    The second Rx (with a new volume of fluid) will generally last 2-6 years. Symptoms in most cases are 100% gone, but possibly an orthotic has ruptured and in speaking with the pt, they may say the Rx feels ?subtle? rather than ?full/snug?. I will increase the volume 3-6 gms in 2 different Rx, and see which is most comfortable with function and with a return of a fuller sensation.

    That becomes the new Rx and most probably will last for their lifetime. I have found that a bio-fluid technology Rx can change once more between 6-10 years as well.

    It is my experience the foot does not change ?shape?--because of the reduction in tension and inflammation, the ROM increases and readily accepts a greater volume of fluid to counter the increase in pronation motion.


    A question I would add to your decision making thoughts is: How reliable is a patient's feedback in determining 'suspicions of orthotic fatigue or a return of symptoms'?

    In my case, the pt's feedback is everything.
  24. Dennis Kiper

    Dennis Kiper Active Member


    (If they wear through a pair of shoes each year, they will probably wear their orthotics out sooner than most people do )

    I personally do not see wearing out an orthotic comparable to shoes or other equipment.
    Orthotics are biomechanical in function and function I believe is the determining factor.

    In my opinion, when a pt complains about the fit (in fluid technology--?subtle?) or symptoms are returning, then it's time to consider a new Rx orthosis, but not because of any length of time.
  25. True, shoes and orthotics are not comparable as separate components. But when the functioning orthotics and the functioning shoes are functioning together as a unit...then they might see some comparable wear amongst the comparable materials on each.

    When trying to give patients a general guideline to assess the situation (before pain and complaints occur), a periodical check up or observing shoe wear may help them to know when to make an appointment to get checked...thus giving you an opportunity to help them before they are hurting, or at least minimize their pain or discomfort.

    Then your expertise can assess the determining factors....

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