Home The Book Dr Articles Products Message Boards Journal Articles Search Our Surveys Surgery ESWT Dr Messages Find Good Drs video

Is is time for new orthotics?

Posted by Carmel M on 1/07/02 at 13:58 (069078)

I've had PF for 2.5 years now, and have worn custom orthotics for 2 years. The first Pod I saw tried the over-the-counter type of shoe inserts first before casting me for custom orthotics.

I have very rigid 3/4 length orthotics and have just recently began searching for something els that might work better. Since my custom orthotics were not the 'cure all' I think maybe something different or better might be more comfortable.

I met with a CPed in my town who makes custom orthotics. The kind he makes are so different than what I'm wearing now. My insurance paid for the first pair, so maybe they will pay for a second pair.

Has anyone here had good luck with the very rigid type, or is the semi-rigid kind better?

Thanks
Carmel

Re: I have a similar question for the docs

elliott on 1/07/02 at 15:27 (069089)

I tried one pair of hard orthotics a while back without success. I think I know what as wrong with them (in addition to being very hard): although after a few adjustments they fit properly, it was jamming in at that point of the arch of one foot where I already had pain and so increased it, and also I felt my feet trying to slide medially over the edge of the orthotic, possibly because the cover was too slippery. (As an aside, people often ignore the the fact that in order for orthotics to work, they must be coupled with the proper shoe, usually one with a deep heel, medial post and heel counter, and often removable insert as well.)

I've noticed there seem to be two main types of custom orthotics espoused by the esteemed footcare professionals of this board:

1. high-quality very expensive but basic foot-mold orthotics from companies such as Northwest and Footmaxx (the pods), and

2. the cheaper but more more makeshift orthotics ('add a piece on this side, take it away on that side, build up this heel post a little more, add a pad here, lower this there') (Cpeds).

Any comments from the docs as to which is more likely to succeed for which cases?

------

Re: Elliott's astute aside...

Carole C on 1/07/02 at 16:27 (069107)

Elliott, I think you make a good point when you say 'in order for orthotics to work, they must be coupled with the proper shoe, usually one with a deep heel, medial post and heel counter, and often removable insert as well'. The custom orthotics and the shoe work *together*, and I don't think the effect would be the same with another shoe as it is with my big clunky SAS shoes (that the pedorthist put them in and had me buy).

I don't understand the terminology too well but among other virtues these shoes are very good about the heel area. My heel is raised up a little by the orthotic, and still the shoe comes up pretty high beyond that, behind the back of my heel and it is very strong, firm, and not loose there and provides total protection to that part of my Achilles tendon. That seems to help a lot.

Carole C

Re: I have a similar question for the docs

BG CPed on 1/07/02 at 19:26 (069119)

Elliott, Not sure how your explaination should be taken. No offense but I would like to contribute me dos centavos. As for point 1, I would not compare the Northwest product and the Footmaxx, they are night and day different. Northwest makes in my opinion the best carbon device anywhere. They have a great lab and the labor involved is very intensive.

Footmaxx is an ok device but it is a modified prefab matched to a dynamic wt bearing impression, no actual cast is used. They pick the closest shell and modify it.

Point 2 The add a piece here, take a piece off, build this up (CPed) I can only speak for myself but I do that maybe 2 times a month and I make over 100 pair per month. Again I am not nitpicking but that makes it sound like a seat of the pants crapshoot. The fact that most CPed have a lab on site makes it easier when/if you need adjustments.

I use a digital scanner and milling machine for most of my devices. I do have some instances where I need to re-do or adjust but 95% of mine never come back unless they need a new pair or to buy another shoe.

Just wanted to clarify so any newbies reading this dont get the wrong idea

Re: well, actually...

elliott on 1/07/02 at 21:57 (069139)

I meant it in a positive way, that the final product is not really final, but that you can make more than just minor adjustments and still make it work out, and that this would be a big plus, possibly outweighing the superior material of a more expensive but 'permanent' orthotic. Sorry if that was unclear.

I've just switched to BCBS, which will cover a good chunk of one pair of orthotics annually. After seeing a few people here try NW's orthotics without out success, I've been getting this sinking feeling that maybe the kind you can alter extensively afterwards is the way to go. Now you're saying that such extensive alterations are anyway rare. So if given the choice, something like NW is the way to go?

------

Re: well, actually...

BG CPed on 1/08/02 at 07:04 (069159)

Thanks Elliott. The NW lad makes the best graphite device BUT it is firm. The device is only as good as the cast and what the person that made it asks to be done. The lab can eval the cast and call and make suggestions but who sent it has the ultimate responsibilty.

Harder isnt better always ans softer isnt always. I have to tweak them also at times. One advantage I have is doing both shoes and orthotics (which we do in an hour) I am the one that does the eval, fabricates and fits for new shoes if needed so that is imho a key to higher success rate.

I see too many pt that have a device that has failed and they are in a poor shoe. When I ask if the were given break in instructions or had footwear evaled they say no the assistant handed them to me and said 'wear em in all your shoes' It is a problem in the orthotic industry and I am not too sure what the answer is.

Thanks for clearing that up for me

Re: So what you're saying is...

Carmel M on 1/08/02 at 18:32 (069259)

...that I would probably do better with the local CPed in my town, versus trying to get my Pod to order a new pair of orthotics. Do all podiatrists order the hard type of orthotic?

What I notice lately is that softer feels so much better. I only wear my orthotics in athletic shoes (usually New Balance), but around the house I wear Naot sandals (similar to Birkenstock) and they have the softer footbed. I find myself taking off my shoes and wearing the Naot's at least half the time I'm on my feet.

Carmel

Re: soft vs. semi-rigid vs. hard

elliott on 1/08/02 at 22:16 (069285)

I would love to hear BG CPed's views as to when typically to prescribe each of these. In case you think it's as simple as high arch = soft, low arch = hard, I recall seeing a rather large study claiming that, counterintuitively, the higher-arched did better in hard. Furthermore, a big drawback to soft is they don't last that long--as short as a year or less, at least for runners (compared to hard, which can last a decade). Big deal if soft's $200 instead of $400; if you have to replace it annually, it ain't so cheap, and a nuisance too.

----

Re: soft vs. semi-rigid vs. hard

BG CPed on 1/08/02 at 23:06 (069288)

The hard soft debate is likly to go on forever like a holy war. There are good and bad about both, not in the material itself but more relative to the practitioners choice. The persons foot function and symptoms are just a few of the factors involved in the success of the device.

IMHO the modifications and posting have a greater influence. Some feet can tolerate a golf ball in the shoe and some are princess and the pea and will complain about nothing. I would rather have a skilled person make them for me out of either materials.

The main reason many 'hard' devices fail is that they are notposted or over posted correctly. It is also a factor when the device is trying to control the foot by jacking the arch up.

A typical scenario is a person with moderate to excessive pronation will have a device that they say they used for a week or two and tossed it in the drawer. The device will be 3/4, hard material, high arch and a post that is relativly neutral.

The pt has tight heel cords, mid foot and late stage pronation. Because the device is not posted to deal with forefoot (dont always need ff post)has no or minimal rearfoot post and is using the arch to control the foot. This can make the device hurt the arch and also in some case put traction on the fascia, almost like a speed bump across the middle of the foot

I use 65 durometer eva in 99% of my devices. The posting material is much harder. That is about as hard as the firm part of a running shoe sole. I only use graphite for dress orthotics or for figure/hockey skaters due to the limited space available. If you pronate I would ask your guy to reduce the medial arch and add a few degree of rearfoot post, may also want to try a firmer shoe like a running or cross trainer.

The heel needs to be stabilized and controled, if it is allowed to evert too much the device is flawed from the start. The best case is that the person that provides the device have some equipment on site and not have to send it out to get it adjusted.

It may be too much work for Scott but maybe a section that people can post a pic of their feet wt bearing and their shoes and fo so that some of the docs and Cpeds can see would help. Not for everybody to just start posting all kinds of pics but for the real problem ones. It is hard tell what all the problems are when you cant see the foot, shoe and orthotic.

I am sure we would all agree that at least once a day we get a pt that says they either have high arch or pronation and they are 180 degree off.

Re: soft vs. semi-rigid vs. hard

Carole C on 1/09/02 at 11:50 (069339)

BG,

That's a good point.

I had been so sure all my life that I had flat feet, but my doctor and my pedorthist both independantly told me that I have high arches! I am sure they are right, because the orthotics that were made for me work so well. I can imagine that sometimes others might also have a mistaken idea of their arch height.

Carole C

Re: soft vs. semi-rigid vs. hard

Ed Davis, DPM on 1/09/02 at 22:09 (069427)

I avoid the hard vs. soft debate as much as possible because I prefer to focus on what it takes to provide the right amount of biomechanical control based on the needs of a patient. Control can be a function of the shape of the device, width of the device, deepness of the heel cup as well as material flexibility. Individual needs vary with pathology, weight, occupation, avocation, joint flexibility, age, etc.

My only bias is that more rigid device require that the practitioner and orthotic fabricator use a higher level of precision since the device is less forgiving than a softer one. Labs which are inferior or inexperienced practitioners often need to use softer devices or devices that contour less closely to the foot, trading comfort for therapeutic effect---the devices feel comfortable to the patient but they are still hurting. There are a lot of people dabbling in the 'orthotic business' as a sideline who have minimal training or because they want to add a new 'profit center' to their office. Some of the manufacturers selling automated devices have been dangling the 'profit' carrot and are partially responsible for this trend.

Ultimately, a practitioner who understands the needs of the patient and has the training to create a wide variety of devices can best serve patient needs. Orthotics are not a cure all but there really should be few orthotic failures if the practitioner is able and willing to meet the needs of the patient.
Ed

Re: regarding your last sentence

elliott on 1/09/02 at 22:56 (069435)

you seem to have a lot more faith than most of us here that orthotics if only done right will almost always work. Most of us take the view that it's another thing to try which might work (in which case great) but usually doesn't; that seems to be the more typical experience here, even when we go to highly recommended pods who give highly recommended orthotics. Our view is more like, if you try a lot of even low-probability remedies, something or some combination might just work, but any particular remedy (including orthotics) probably won't. Of course, there's that old argument that maybe we at heelspurs aren't typical, because if orthotics cured us, we would never have stumbled upon this site. :-)

---

Re: soft vs. semi-rigid vs. hard

BG CPed on 1/09/02 at 23:50 (069450)

Well said Dr Ed, my point, just better stated. The material is not as important ans the shape and correction of the device. I have treated some pretty nasty cases of ptti with a hard eva device and solid shoe + right amount of posting. I think there should be more training and regulation regarding orthotics.

Anybody on this board can buy the materials or machines and start making them tomorrow with no problems. I feel sad to admit but there are more medium to bad orthotic providers out there than good to great ones. I get folks in that will have a small bag of bad evices and they want to show them all to me. I can usually tell them in 1 minute where they got them, what lab made them and why they dont work (all in a diplomatic way)

There are a few labs out there, as I am sure Dr Ed and Z would agree that do a poor job. The little shell with the practice name on the top and the cookie cutter shell? If you put 10 pair side by side they would look identical. I think I get madder than the pt sometimes when they start pulling all the stuff out of the bag that didnt work on anything but their wallet.

Thats enough for now, better go before I piss somebody off ( can I say piss on here Scott?)

Re: regarding your last sentence

Ed Davis, DPM on 1/11/02 at 19:52 (069691)

Elliott:
I don't think that posters on this board represent a typical cross section of plantar fasciitis sufferers. A lot of individuals here have difficult cases, incomplete or inadequate treatment or treatment failures and are at one end of the 'bell curve.'

My opinion on orthotics is not based on faith but on experience. My experience coupled with that of my colleagues shows that orthotics work in a high percentage of plantar fasciitis cases. If I had plantar fasciitis personally and could only do one thing, I would opt for orthotics. I do not have a study to quote but would estimate that I have treated approximately 6000 to 7000 cases of plantar fasciitis with orthotics in my
career with better than 90% of patients being successful with this modality. I generally follow patients until they are asymptomatic so I am quite confident of these numbers.
Ed

Re: regarding your last sentence

Carole C on 1/11/02 at 20:00 (069693)

Custom orthotics have sure worked for me.

Carole C

Re: regarding your last sentence

BG CPed on 1/11/02 at 20:39 (069702)

Well stated as usual Dr Ed. Being a CPed I dont have the option of surgical intervention or injection. If I cant reduce or eliminate symptoms via conservative modalities e.g shoe and or orthotics I have failed. I fabricate about 1300 foot orthotics per year and have about a 95% success rate.
Also to keep in mind, most of my pt are from Doctors that specialize in feet and see many bad cases. 65% of pt I see have been treated previously and have had orthotics at some point.

I would say that the 2 main factors in orthotic success would be 1, the number of devices fabricated and success rate of the practitioner 2,the ability of the practitioner to explain his/her goals, objectives and reason for doing what they are doing. In short , this is what your foot is doing or not doing. This is what it SHOULD be doing or not doing. This is what the orthotic and shoes will do. If we BOTH do our job it will work.

In any field further education and training is paramount. Ask any Doctor Lawyer Athlete etc. If they say they knew 90% of what they needed to in both knowledge and experience out of college they are wrong. There are rookies in all fields.

The ones that seek further knowledge and or certification just for c e points become stagnant, and many do.

This is a simple formula but I would say that if it is followed it will work in the vast majority of cases

Re: And maybe also, ...

Carole C on 1/11/02 at 21:07 (069704)

My pedorthist suggested rest, icing, stretching, and similar helpful ideas like we discuss on the board. She also discussed the goals, objectives, and reasons that you mention.

Every now and then I read posts from someone who says their orthotics don't help them, and then they say they've continued their normal daily 10K run or some such mind boggling thing, and haven't been stretching or icing. Maybe I'm wrong, but it seems to me that not only does the C.Ped. or other foot professional have to make good orthotics, but also the patient has to give the orthotics a chance to help. If I had yielded to the temptation to use my feet as much as always, and if I had not stretched, I don't think my orthotics would have worked as well as they have.

I could be wrong, though, since I don't know much about this at all. I had no interest or exposure to foot problems and feet before last September when I got PF.

Carole C

Re: regarding your last sentence

Carole C on 1/11/02 at 21:16 (069705)

Hey Elliott, orthotics are healing me but I'm still here and I've even got my photo in the photo section. :)

I found heelspurs.com when I was wondering if I had heelspurs, and it took a month after that for me to get to the doctor and get an x-ray. Then it took another 2.5 weeks before I got my orthotics. I've had them for one month and one day, and they are definitely helping me to heal. As you might agree, it takes a long time to heal PF and so I am not completely healed yet.

So, I'll probably be around for a while!

I'm not saying that custom orthotics are 'the answer' for everyone, but honestly they do work for some of us.

Carole C

Re: what do you make of this?

elliott on 1/12/02 at 20:39 (069811)

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11266478&dopt=Abstract

---

Re: what do you make of this?

BG CPed on 1/12/02 at 21:27 (069822)

From what I could gather from just the abstract was that fo were the best of the 'worse'. I would doubt the results that said all 3 were equal, there are too many variables. There was another study done in the San Fran area ( I think ) They claimed that out of custom fo,pre-fab or gel heel cups that heel cups were most effective.

It was flawed for a few reasons, 1, A heel cup company funded it. 2,They used several different people to evaluate and cast for the customs, BIG MISTAKE! 3, They then released a portion of the result to mainstream media so it read to the masses 'heel cups great, custom insert rip-off and dont work' I remember getting a few calls from pt wanting to know why I didnt use heel cups.

If I am not mistaken the lab they used was very reputable and really was p.o.'ed at the methodology. I am sure some others on here may remember it or have more info on it.

Re: can I ask you and the pods this?

elliott on 1/12/02 at 21:43 (069824)

Regarding the link I supplied, is the 3 months long enough to measure the efficacy of orthotics or is that more like a total joke?

---

Re: can I ask you and the pods this?

BG CPed on 1/13/02 at 01:00 (069845)

I cant speak for all but 3 months should be a reasonable time to evaluate if it have a positive effect. A night splint will usually have the fastest most positive results upon rising out of bed, the first 'few steps' in the am that take about 10 minutes to decrease.

In the case of pf or pttt most pt will note a decrease in symptoms when they stand up after being fit with proper shoe and fo. I dont mean to imply that it is cured but if symptoms are biomechanic related and shoes are wrong then changing function and offloading foot will usually reduce the pain in those first few steps.

Night splints work well for some. I have found that most pt that dont like night splint either try to set them too much into dorsiflexion too soon. It is better to leave it at 90 degree for the first few days. On the adustable type many folks think if 90 deg is good then really crank it up and it will work better. Most complaints are that it either makes the forefoot numb, burn or tingle so they kick it off.

Night splint needs to be broken in or eased into just like orthotics or birks for best results. So I would say that at 3 months you should definatly have an idea of the efficacy of a certain device. It may take longer to get complete relief but I would say that a device of any type should show some improvement within first 2 weeks if not sooner.

Obviously that is based on the assumption that the correct dx has been made and the device has been fit properly and the pt was given proper instructions. That may seem silly but I have seen too many pt receive devices with no instructions.

Re: what do you make of this?

Ed Davis, DPM on 1/14/02 at 16:11 (069975)

This would be at odds with my experience and that of colleagues. I would need to know more about how the study was set up, the variables and the type of custom orthotics used.
Ed

Re: I have a similar question for the docs

susan L on 1/15/02 at 00:15 (070007)

Does anyone know approx how long custom orthotics last before you need new ones. Is 12 years too long. Thanks

Re: I have a similar question for the docs

BG CPed on 1/15/02 at 06:53 (070011)

12 years is too too long. They may feel ok but most likely the material has deformed and your foot has changed a little. Think of a pair of glasses. If you pulled out a pair that were 12 y/o they would probably work better than nothing but not as much correction as a new pair.
How long they last is dependant on many factors, material, your foot, wt changes, and how much you wear them.

I would suggest you get in to see somebody for a new pair

Re: I have a similar question for the docs

elliott on 1/07/02 at 15:27 (069089)

I tried one pair of hard orthotics a while back without success. I think I know what as wrong with them (in addition to being very hard): although after a few adjustments they fit properly, it was jamming in at that point of the arch of one foot where I already had pain and so increased it, and also I felt my feet trying to slide medially over the edge of the orthotic, possibly because the cover was too slippery. (As an aside, people often ignore the the fact that in order for orthotics to work, they must be coupled with the proper shoe, usually one with a deep heel, medial post and heel counter, and often removable insert as well.)

I've noticed there seem to be two main types of custom orthotics espoused by the esteemed footcare professionals of this board:

1. high-quality very expensive but basic foot-mold orthotics from companies such as Northwest and Footmaxx (the pods), and

2. the cheaper but more more makeshift orthotics ('add a piece on this side, take it away on that side, build up this heel post a little more, add a pad here, lower this there') (Cpeds).

Any comments from the docs as to which is more likely to succeed for which cases?

------

Re: Elliott's astute aside...

Carole C on 1/07/02 at 16:27 (069107)

Elliott, I think you make a good point when you say 'in order for orthotics to work, they must be coupled with the proper shoe, usually one with a deep heel, medial post and heel counter, and often removable insert as well'. The custom orthotics and the shoe work *together*, and I don't think the effect would be the same with another shoe as it is with my big clunky SAS shoes (that the pedorthist put them in and had me buy).

I don't understand the terminology too well but among other virtues these shoes are very good about the heel area. My heel is raised up a little by the orthotic, and still the shoe comes up pretty high beyond that, behind the back of my heel and it is very strong, firm, and not loose there and provides total protection to that part of my Achilles tendon. That seems to help a lot.

Carole C

Re: I have a similar question for the docs

BG CPed on 1/07/02 at 19:26 (069119)

Elliott, Not sure how your explaination should be taken. No offense but I would like to contribute me dos centavos. As for point 1, I would not compare the Northwest product and the Footmaxx, they are night and day different. Northwest makes in my opinion the best carbon device anywhere. They have a great lab and the labor involved is very intensive.

Footmaxx is an ok device but it is a modified prefab matched to a dynamic wt bearing impression, no actual cast is used. They pick the closest shell and modify it.

Point 2 The add a piece here, take a piece off, build this up (CPed) I can only speak for myself but I do that maybe 2 times a month and I make over 100 pair per month. Again I am not nitpicking but that makes it sound like a seat of the pants crapshoot. The fact that most CPed have a lab on site makes it easier when/if you need adjustments.

I use a digital scanner and milling machine for most of my devices. I do have some instances where I need to re-do or adjust but 95% of mine never come back unless they need a new pair or to buy another shoe.

Just wanted to clarify so any newbies reading this dont get the wrong idea

Re: well, actually...

elliott on 1/07/02 at 21:57 (069139)

I meant it in a positive way, that the final product is not really final, but that you can make more than just minor adjustments and still make it work out, and that this would be a big plus, possibly outweighing the superior material of a more expensive but 'permanent' orthotic. Sorry if that was unclear.

I've just switched to BCBS, which will cover a good chunk of one pair of orthotics annually. After seeing a few people here try NW's orthotics without out success, I've been getting this sinking feeling that maybe the kind you can alter extensively afterwards is the way to go. Now you're saying that such extensive alterations are anyway rare. So if given the choice, something like NW is the way to go?

------

Re: well, actually...

BG CPed on 1/08/02 at 07:04 (069159)

Thanks Elliott. The NW lad makes the best graphite device BUT it is firm. The device is only as good as the cast and what the person that made it asks to be done. The lab can eval the cast and call and make suggestions but who sent it has the ultimate responsibilty.

Harder isnt better always ans softer isnt always. I have to tweak them also at times. One advantage I have is doing both shoes and orthotics (which we do in an hour) I am the one that does the eval, fabricates and fits for new shoes if needed so that is imho a key to higher success rate.

I see too many pt that have a device that has failed and they are in a poor shoe. When I ask if the were given break in instructions or had footwear evaled they say no the assistant handed them to me and said 'wear em in all your shoes' It is a problem in the orthotic industry and I am not too sure what the answer is.

Thanks for clearing that up for me

Re: So what you're saying is...

Carmel M on 1/08/02 at 18:32 (069259)

...that I would probably do better with the local CPed in my town, versus trying to get my Pod to order a new pair of orthotics. Do all podiatrists order the hard type of orthotic?

What I notice lately is that softer feels so much better. I only wear my orthotics in athletic shoes (usually New Balance), but around the house I wear Naot sandals (similar to Birkenstock) and they have the softer footbed. I find myself taking off my shoes and wearing the Naot's at least half the time I'm on my feet.

Carmel

Re: soft vs. semi-rigid vs. hard

elliott on 1/08/02 at 22:16 (069285)

I would love to hear BG CPed's views as to when typically to prescribe each of these. In case you think it's as simple as high arch = soft, low arch = hard, I recall seeing a rather large study claiming that, counterintuitively, the higher-arched did better in hard. Furthermore, a big drawback to soft is they don't last that long--as short as a year or less, at least for runners (compared to hard, which can last a decade). Big deal if soft's $200 instead of $400; if you have to replace it annually, it ain't so cheap, and a nuisance too.

----

Re: soft vs. semi-rigid vs. hard

BG CPed on 1/08/02 at 23:06 (069288)

The hard soft debate is likly to go on forever like a holy war. There are good and bad about both, not in the material itself but more relative to the practitioners choice. The persons foot function and symptoms are just a few of the factors involved in the success of the device.

IMHO the modifications and posting have a greater influence. Some feet can tolerate a golf ball in the shoe and some are princess and the pea and will complain about nothing. I would rather have a skilled person make them for me out of either materials.

The main reason many 'hard' devices fail is that they are notposted or over posted correctly. It is also a factor when the device is trying to control the foot by jacking the arch up.

A typical scenario is a person with moderate to excessive pronation will have a device that they say they used for a week or two and tossed it in the drawer. The device will be 3/4, hard material, high arch and a post that is relativly neutral.

The pt has tight heel cords, mid foot and late stage pronation. Because the device is not posted to deal with forefoot (dont always need ff post)has no or minimal rearfoot post and is using the arch to control the foot. This can make the device hurt the arch and also in some case put traction on the fascia, almost like a speed bump across the middle of the foot

I use 65 durometer eva in 99% of my devices. The posting material is much harder. That is about as hard as the firm part of a running shoe sole. I only use graphite for dress orthotics or for figure/hockey skaters due to the limited space available. If you pronate I would ask your guy to reduce the medial arch and add a few degree of rearfoot post, may also want to try a firmer shoe like a running or cross trainer.

The heel needs to be stabilized and controled, if it is allowed to evert too much the device is flawed from the start. The best case is that the person that provides the device have some equipment on site and not have to send it out to get it adjusted.

It may be too much work for Scott but maybe a section that people can post a pic of their feet wt bearing and their shoes and fo so that some of the docs and Cpeds can see would help. Not for everybody to just start posting all kinds of pics but for the real problem ones. It is hard tell what all the problems are when you cant see the foot, shoe and orthotic.

I am sure we would all agree that at least once a day we get a pt that says they either have high arch or pronation and they are 180 degree off.

Re: soft vs. semi-rigid vs. hard

Carole C on 1/09/02 at 11:50 (069339)

BG,

That's a good point.

I had been so sure all my life that I had flat feet, but my doctor and my pedorthist both independantly told me that I have high arches! I am sure they are right, because the orthotics that were made for me work so well. I can imagine that sometimes others might also have a mistaken idea of their arch height.

Carole C

Re: soft vs. semi-rigid vs. hard

Ed Davis, DPM on 1/09/02 at 22:09 (069427)

I avoid the hard vs. soft debate as much as possible because I prefer to focus on what it takes to provide the right amount of biomechanical control based on the needs of a patient. Control can be a function of the shape of the device, width of the device, deepness of the heel cup as well as material flexibility. Individual needs vary with pathology, weight, occupation, avocation, joint flexibility, age, etc.

My only bias is that more rigid device require that the practitioner and orthotic fabricator use a higher level of precision since the device is less forgiving than a softer one. Labs which are inferior or inexperienced practitioners often need to use softer devices or devices that contour less closely to the foot, trading comfort for therapeutic effect---the devices feel comfortable to the patient but they are still hurting. There are a lot of people dabbling in the 'orthotic business' as a sideline who have minimal training or because they want to add a new 'profit center' to their office. Some of the manufacturers selling automated devices have been dangling the 'profit' carrot and are partially responsible for this trend.

Ultimately, a practitioner who understands the needs of the patient and has the training to create a wide variety of devices can best serve patient needs. Orthotics are not a cure all but there really should be few orthotic failures if the practitioner is able and willing to meet the needs of the patient.
Ed

Re: regarding your last sentence

elliott on 1/09/02 at 22:56 (069435)

you seem to have a lot more faith than most of us here that orthotics if only done right will almost always work. Most of us take the view that it's another thing to try which might work (in which case great) but usually doesn't; that seems to be the more typical experience here, even when we go to highly recommended pods who give highly recommended orthotics. Our view is more like, if you try a lot of even low-probability remedies, something or some combination might just work, but any particular remedy (including orthotics) probably won't. Of course, there's that old argument that maybe we at heelspurs aren't typical, because if orthotics cured us, we would never have stumbled upon this site. :-)

---

Re: soft vs. semi-rigid vs. hard

BG CPed on 1/09/02 at 23:50 (069450)

Well said Dr Ed, my point, just better stated. The material is not as important ans the shape and correction of the device. I have treated some pretty nasty cases of ptti with a hard eva device and solid shoe + right amount of posting. I think there should be more training and regulation regarding orthotics.

Anybody on this board can buy the materials or machines and start making them tomorrow with no problems. I feel sad to admit but there are more medium to bad orthotic providers out there than good to great ones. I get folks in that will have a small bag of bad evices and they want to show them all to me. I can usually tell them in 1 minute where they got them, what lab made them and why they dont work (all in a diplomatic way)

There are a few labs out there, as I am sure Dr Ed and Z would agree that do a poor job. The little shell with the practice name on the top and the cookie cutter shell? If you put 10 pair side by side they would look identical. I think I get madder than the pt sometimes when they start pulling all the stuff out of the bag that didnt work on anything but their wallet.

Thats enough for now, better go before I piss somebody off ( can I say piss on here Scott?)

Re: regarding your last sentence

Ed Davis, DPM on 1/11/02 at 19:52 (069691)

Elliott:
I don't think that posters on this board represent a typical cross section of plantar fasciitis sufferers. A lot of individuals here have difficult cases, incomplete or inadequate treatment or treatment failures and are at one end of the 'bell curve.'

My opinion on orthotics is not based on faith but on experience. My experience coupled with that of my colleagues shows that orthotics work in a high percentage of plantar fasciitis cases. If I had plantar fasciitis personally and could only do one thing, I would opt for orthotics. I do not have a study to quote but would estimate that I have treated approximately 6000 to 7000 cases of plantar fasciitis with orthotics in my
career with better than 90% of patients being successful with this modality. I generally follow patients until they are asymptomatic so I am quite confident of these numbers.
Ed

Re: regarding your last sentence

Carole C on 1/11/02 at 20:00 (069693)

Custom orthotics have sure worked for me.

Carole C

Re: regarding your last sentence

BG CPed on 1/11/02 at 20:39 (069702)

Well stated as usual Dr Ed. Being a CPed I dont have the option of surgical intervention or injection. If I cant reduce or eliminate symptoms via conservative modalities e.g shoe and or orthotics I have failed. I fabricate about 1300 foot orthotics per year and have about a 95% success rate.
Also to keep in mind, most of my pt are from Doctors that specialize in feet and see many bad cases. 65% of pt I see have been treated previously and have had orthotics at some point.

I would say that the 2 main factors in orthotic success would be 1, the number of devices fabricated and success rate of the practitioner 2,the ability of the practitioner to explain his/her goals, objectives and reason for doing what they are doing. In short , this is what your foot is doing or not doing. This is what it SHOULD be doing or not doing. This is what the orthotic and shoes will do. If we BOTH do our job it will work.

In any field further education and training is paramount. Ask any Doctor Lawyer Athlete etc. If they say they knew 90% of what they needed to in both knowledge and experience out of college they are wrong. There are rookies in all fields.

The ones that seek further knowledge and or certification just for c e points become stagnant, and many do.

This is a simple formula but I would say that if it is followed it will work in the vast majority of cases

Re: And maybe also, ...

Carole C on 1/11/02 at 21:07 (069704)

My pedorthist suggested rest, icing, stretching, and similar helpful ideas like we discuss on the board. She also discussed the goals, objectives, and reasons that you mention.

Every now and then I read posts from someone who says their orthotics don't help them, and then they say they've continued their normal daily 10K run or some such mind boggling thing, and haven't been stretching or icing. Maybe I'm wrong, but it seems to me that not only does the C.Ped. or other foot professional have to make good orthotics, but also the patient has to give the orthotics a chance to help. If I had yielded to the temptation to use my feet as much as always, and if I had not stretched, I don't think my orthotics would have worked as well as they have.

I could be wrong, though, since I don't know much about this at all. I had no interest or exposure to foot problems and feet before last September when I got PF.

Carole C

Re: regarding your last sentence

Carole C on 1/11/02 at 21:16 (069705)

Hey Elliott, orthotics are healing me but I'm still here and I've even got my photo in the photo section. :)

I found heelspurs.com when I was wondering if I had heelspurs, and it took a month after that for me to get to the doctor and get an x-ray. Then it took another 2.5 weeks before I got my orthotics. I've had them for one month and one day, and they are definitely helping me to heal. As you might agree, it takes a long time to heal PF and so I am not completely healed yet.

So, I'll probably be around for a while!

I'm not saying that custom orthotics are 'the answer' for everyone, but honestly they do work for some of us.

Carole C

Re: what do you make of this?

elliott on 1/12/02 at 20:39 (069811)

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11266478&dopt=Abstract

---

Re: what do you make of this?

BG CPed on 1/12/02 at 21:27 (069822)

From what I could gather from just the abstract was that fo were the best of the 'worse'. I would doubt the results that said all 3 were equal, there are too many variables. There was another study done in the San Fran area ( I think ) They claimed that out of custom fo,pre-fab or gel heel cups that heel cups were most effective.

It was flawed for a few reasons, 1, A heel cup company funded it. 2,They used several different people to evaluate and cast for the customs, BIG MISTAKE! 3, They then released a portion of the result to mainstream media so it read to the masses 'heel cups great, custom insert rip-off and dont work' I remember getting a few calls from pt wanting to know why I didnt use heel cups.

If I am not mistaken the lab they used was very reputable and really was p.o.'ed at the methodology. I am sure some others on here may remember it or have more info on it.

Re: can I ask you and the pods this?

elliott on 1/12/02 at 21:43 (069824)

Regarding the link I supplied, is the 3 months long enough to measure the efficacy of orthotics or is that more like a total joke?

---

Re: can I ask you and the pods this?

BG CPed on 1/13/02 at 01:00 (069845)

I cant speak for all but 3 months should be a reasonable time to evaluate if it have a positive effect. A night splint will usually have the fastest most positive results upon rising out of bed, the first 'few steps' in the am that take about 10 minutes to decrease.

In the case of pf or pttt most pt will note a decrease in symptoms when they stand up after being fit with proper shoe and fo. I dont mean to imply that it is cured but if symptoms are biomechanic related and shoes are wrong then changing function and offloading foot will usually reduce the pain in those first few steps.

Night splints work well for some. I have found that most pt that dont like night splint either try to set them too much into dorsiflexion too soon. It is better to leave it at 90 degree for the first few days. On the adustable type many folks think if 90 deg is good then really crank it up and it will work better. Most complaints are that it either makes the forefoot numb, burn or tingle so they kick it off.

Night splint needs to be broken in or eased into just like orthotics or birks for best results. So I would say that at 3 months you should definatly have an idea of the efficacy of a certain device. It may take longer to get complete relief but I would say that a device of any type should show some improvement within first 2 weeks if not sooner.

Obviously that is based on the assumption that the correct dx has been made and the device has been fit properly and the pt was given proper instructions. That may seem silly but I have seen too many pt receive devices with no instructions.

Re: what do you make of this?

Ed Davis, DPM on 1/14/02 at 16:11 (069975)

This would be at odds with my experience and that of colleagues. I would need to know more about how the study was set up, the variables and the type of custom orthotics used.
Ed

Re: I have a similar question for the docs

susan L on 1/15/02 at 00:15 (070007)

Does anyone know approx how long custom orthotics last before you need new ones. Is 12 years too long. Thanks

Re: I have a similar question for the docs

BG CPed on 1/15/02 at 06:53 (070011)

12 years is too too long. They may feel ok but most likely the material has deformed and your foot has changed a little. Think of a pair of glasses. If you pulled out a pair that were 12 y/o they would probably work better than nothing but not as much correction as a new pair.
How long they last is dependant on many factors, material, your foot, wt changes, and how much you wear them.

I would suggest you get in to see somebody for a new pair