Welcome to the Podiatry Arena forums

You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members, upload content, view attachments, receive a weekly email update of new discussions, access other special features. Registered users do not get displayed the advertisements in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!

  1. Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
Dismiss Notice
Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
Dismiss Notice
Have you liked us on Facebook to get our updates? Please do. Click here for our Facebook page.
Dismiss Notice
Do you get the weekly newsletter that Podiatry Arena sends out to update everybody? If not, click here to organise this.

Perception of Casting Patient's for orthoses at the Initial Visit

Discussion in 'Biomechanics, Sports and Foot orthoses' started by whols, Apr 16, 2010.

  1. whols

    whols Member


    Members do not see these Ads. Sign Up.
    I have had a few discussions over the last week or so with different podiatrists in regards to casting a patient for orthoses at the initial consultation. I would like different perceptions (whether you also cast at intial or trial a treatment before casting your patients) and what influences your decision in this situation? Do you beleive your success rates in terms of effectiveness of orthoses are high if you cast on the first consultation and appointments after?
     
  2. Hi Aaron

    It really depends on the situation are I have no goldern rule. I will decide to cast or not cast on which method I beleive will have the fastest result for the patient. ie which treatment path will in my option reduce their symptoms the fastest. I do have lots of patients that do not get orthotics at all.

    I will generally be a little more conservative with casting in those very nervy type patients - It´s a feeling I get, the ones who change shoe 4 times a day have tried 10 devices before etc.
     
  3. davidl

    davidl Member

    Welcome to posting Aaron

    I agree with Michael that it totally depends on the case and circumstances. I take the view (working in UK NHS) that I give the minimum required to get the job done and use a library-type system as often this is sufficient to deliver the desired effect and get the patient better.

    Concur that some do need orthoses at all, but if they do need a casted device, thats what they get, and it is initiated straight away, assuming they are on board with other requirements of the treatment plan e.g. change in footwear to accommodate orthotic devices.
    Regards, David
     
  4. efuller

    efuller MVP

    This is partly a matter of time. If someone is referred to me for orthotics I schedule them for enough time to do the casting. A normal initial visit usually does not have the time budgeted for casting and eval for orhtotics.

    Eric
     
  5. PodAus

    PodAus Active Member

    Hi Guys,

    I regularly hear from new patients whom have sought treatment before, "the plan was to tape my feet to see if I got better. Then if I did, then maybe orthotics would help". Sometimes the pt then reports not returning as did "get better"; others report "no relief from taping but told to try orthotics anyway".

    Why would you trial something to see if orthoses are relevant when the nature of a mechanical stress issue is apparent from the initial presentation?
    This can lead to confusion on behalf of the patient and the practitioner; is this just relecting guesswork, or just doing something to see what may happen, without a clear understanding of the factors relating to the symptoms / presentation?

    Assess the risk factors, form a D/Dx and consider the appropriate treatment options. Time restraints - yes definitely next appt for initiation treatment plan, but
    certainly clarify what, why, how, when, with pt at initial.
    More consultations just cost the patient more.

    :morning:
     
  6. PowerPodiatry

    PowerPodiatry Active Member

    Orthoses seem to be the death of diagnosis.

    The orthoses fixes all (including the pod's bank balance) is all that many Pod's can come up with these days.

    Sad bunch you are, no wonder the number of complaints to the relevant authorities has escalated.

    First diagnose then test the theory, your patient will be much happier and you may even open your eyes to other modalities of treatment.

    I could go on but :bash:
     
  7. PodAus

    PodAus Active Member

    Orthoses correctly prescribed and implimented are proven without a shred of doubt, to change tissue stress patterns. Used in conjunction with physical therapy modalities, difficult for pt not to get better.

    Simple.
     
  8. PowerPodiatry

    PowerPodiatry Active Member

    Yes Very Simple.

    So everything in life is due to mechanical stress in the local region of the foot.

    Next....
     
  9. Lab Guy

    Lab Guy Well-Known Member

    If I saw a podiatrist for the first time and left the office after being casted for orthotics (and probably x-rays and whatever else was done for me), I may have buyer's remorse. I may question what I was thinking to rush into having spent so much money at an office I visited for the first time. I also may think the doctor was only thinking of his pocketbook being so aggressive.

    I like to try to connect to my patients on their first visit and earn their trust. On the first visit, I will do my best to find the underlying reason why they presented to me with their chief complaint. I may also order radiographs to help me reach the proper diagnosis.

    In many patients I will perform micromanipulation (founder was Dr. Crotty who passed away) which I have had great success with. I do not charge for manipulation but for strapping and padding which I do afterwards. The manipulation is gentle, and patients love to be touched and most obtain immediate relief (although this is not always possible). If there is acute pain, I may also give an injection of steroid with Bupivicane to reduce inflammation and break up the pain cycle. I will then discuss my future plan and will commonly tell them that orthotics will benefit them. I plant the seed on the first visit and do not discuss costs associated with the orthotics. I will reappoint my patient in one week in most cases.

    On the second visit, I will discuss orthotics more throughly and tell them how much they are. Most of the time, they feel much better after the first visit and they trust that I know what I am doing. I educate the patient to why the orthotics are important to them and how much better they are going to feel. Remember, people will more likely pay for what they Want, not what they Need and I frame my questions to this end.

    I treat my patients how I want to be treated. I tell my patients upfront prior to casting them, that if they are not fully satisfied with their orthotics they may return them for a full refund. This then prevents buyer's remorse as it gives the patient an out. I also do not want to add salt to their wounds if they are not happy with the orthotics. Now, I would say 5% or so of my patients cannot tolerate their orthotics for various reasons but it is still rare when my patient will ask for a refund as they know my intention was heart-felt.

    I will also end this post to tell you that if everyone was casted for custom orthotics, I think that would be a good thing. Custom orthotics are a great investment, will prevent problems and most will last a lifetime (with minor costs for rejuvenation). I have patients that will come in with a chief complaint of an ingrown nail and invariably they would end up getting a pair of orthotics and love them as they never realized how good they could feel. Intent is everything and my intent is not sell but to educate my patients and allow then to experience for themselves how good they could feel (through manip/taping). That has been my philosophy.

    Steven
     
  10. PodAus

    PodAus Active Member

    Well said Steven.
    Couldn't agree more.
    Case by case and lots of happy patients for many years to come.

    Suppose that's what makes great Practitioners.
     
  11. PowerPodiatry

    PowerPodiatry Active Member

    Steven,

    you create long term value for the patient in the day of the quick fix approach. I would be happy to be your patient.

    My concern is that orthoses have become the big hammer in the tool box and if in doubt hit it with the hammer.

    Steven I bet you would do a wonderful differential diagnosis and be constantly questioning.

    Orthoses are a great tool and I have been making and prescribing them since the early 80's so don't get me wrong I use them frequently but only after considerable thought on my part.

    A young college once stated to me "as soon as they come in with heel pain we prescribe orthoses because their is nothing else that can fix it".

    So lets get a differential diagnosis going just encase the pain is not due to localized tissue stress and if you have built TRUST with your patient like Steven has then you may have a 2nd chance at helping.
     
  12. markleigh

    markleigh Active Member

    Steven, what is micromanipulation, how is it performed, how does it differ from "manipulation" & how do you incorporate it into your treatment?
     
  13. Lab Guy

    Lab Guy Well-Known Member

    Thank you Paul and Colin for your kind remarks.

    Markleigh, I will give you a little information regarding Micromanipulation. I realize this is an academic forum and I have no idea how Micromanipulation works.


    Dr. Crotty of Tulsa, OK, who has since passed away, developed micromanipulation. I spent a year learning Micromanipulation from a Podiatrist I worked for that was one of Dr. Crotty’s students. Sadly, Dr. Crotty never published any articles. I was told that Dr. Crotty called his form of manipulation, “Micromanipulation”, for two reasons. One being that he was manipulating the small bones of the foot and the other was that he was using minimal force rather than high velocity thrusting techniques. At its heart, Micromanipulation is the repositioning of subluxed joints of the foot using minimal force. To Dr. Crotty, if there were pain by the joint, then he would define it very broadly as subluxed despite not seeing evidence on radiographs.

    Due to the stress on the ligaments, muscles and joints of the foot during ambulation, it is common for pain to occur along the ligaments or tendons attaching or inserting at the joints as well as the common plantar inter metatarsal nerves. Pain in the foot can cause activation of trigger points of muscles within the leg, thigh, hip, shoulders and even head. Performing Micromanipulation has the potential to help relieve the pain and inflammation by bringing the joints back to their more normal anatomical positions and deactivating the trigger points proximally.

    What is the mechanism of action? I do not know. Academically, I really do not know why micromanipulation works and am not smart enough to know why. Yet, I have used it for 20 plus years and for me its one of my best tools in my toolbox. I also like it because you can never hurt someone using it as its very gentle and patients love being touched and obtaining immediate relief.

    Prior to doing Micromanipulation, I will get a baseline to see where my patient is in terms of points of tenderness in the lower extremity. In the following order I firmly digitally palpate along the iliotibial band, Pes Anserinus, shin, TN joint, sinus tarsi, plantar aspect and dorsal aspect of medial cuneiform and navicular, plantar cuboid, dorsal and plantar interspaces. I report areas of tenderness in my chart so that I can objectively quantify how my treatment is doing. My goal is that upon completion of treatment (with orthotics dispensed) that the above anatomical areas are no longer tender.

    The foundation of Micromanipulation is manipulation of the subtalar joint. When the STJ is manipulated, it causes the relaxation of the intrinsic muscles of the foot and extrinsic muscles of the foot and leg. It allows any subtle malpositioned joints to go back into place.

    Lets manipulate the left STJ. I am sitting in front of my patient who is sitting comfortably in the exam chair.

    My left hand cups the heel with my thumb resting on the anterior surface of the tibia and my fingers under the head of the fibula and on the lateral surface of the heel.

    I rest my right palm on the dorsum of the foot with my little finger on the head of the talus, my second, third and fourth fingers resting on the medial shaft of the first metatarsal and my thumb is resting over the met heads.

    Now, with my left hand cupping the left heel, I pull the heel distally, toward me, distracting and opening up the STJ. I hold this position for about 30 seconds. Then, with my right and left hands in the above positions, I again distract the STJ by pulling the heel and gently rock the foot. The forefoot is moving medially and laterally in the Transverse plane and the Tibia is internally and externally rotating. The Heel is not inverting or everting. You would really have to see it to understand it and even then you would have to practice it a lot before getting it down. Still, if you just open up the STJ by distracting the heel and holding it for 30 seconds, that can be very helpful.

    After manipulation of the STJ, I recheck all the tender spots/trigger points and often they are gone simply be manipulating the STJ. In Micromanipulation, the STJ is the most important joint to manipulate.

    After manipulation, I will apply taping with or without felt padding and instruct the patient to not go barefoot, and wear sandals in the shower. When the patient leaves the exam room and walking, the patient notices how relaxed and light she/he feels. They can feel as if they just had a one hour massage, it is quite amazing. You are helping to make your patient aware of the low grade pain they have been living with all these years.

    On the next appointment, I will recheck the tender points/trigger points to see if there is improvement and report those findings in my chart. I will manipulate again and I will also provide any other treatment that is necessary for the patient’s diagnosis. I will of course schedule my patient for a Biomech exam and casting for orthotics.

    There are many other Micromanipulation techniques and on this post, I focused on the STJ. Let me know if you’re interested in more information and I will post further. Micromanipulation is not a panacea but one of many treatment modalities that serves the patient. In my hands it has proven useful time and time again.

    Steven
     
  14. Jeff Root

    Jeff Root Well-Known Member

    I agree with Steven and Colin that as a rule, it's not a good idea to cast a patient on their initial visit. If for some reason, such as logistics, you do need to cast a patient on their initial visit, then do so without obligation for them to purchase the devices. Tell the patient that you want them to sleep on it and that you want them to confirm their decision in a day or two. Most practitioners don't schedule enough time on an initial visit to do a proper history, biomechanical evaluation, and casting. So why try?

    In addition, when you dispense orthoses, please don't try to coax the patient to respond in a favorable manner. Ask questions but don't say anything that might influence how the patient describes their first impression of their new devices. You can gain valuable clinical feedback if you ask the right questions and listen to the patient's response. This can be an enormous benefit to you and the patient.

    Respectfully,
    Jeff
     
  15. markleigh

    markleigh Active Member

    Thanks Steven for your detailed response. I'm certainly keen to hear further info. on your form of manipulation. While you're at it, what form of strapping do you utilize? My strapping technique is a low-dye which I never seem to vary from. If I can exain how I strap & then whether you are others might offer their version & any alterations you make. I apply a long strap from 5thMPJ around calc to 1st MPJ then 3 short straps from lat. foot under arch to medial side & repeating back towards the calc. Lastly a long strap same as first. I seem to never really vary this strapping technique.
     
Loading...

Share This Page