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Orthotics for feet

Posted by Sunny Jacob - Bayshore on 7/22/02 at 11:34 (090346)

Although ESWT is not a 'stand alone' treatment as suggested, in most cases it has become a last resort or alternative before undergoing surgery.
Unfortunately, additional needs have to be addressed, including orthotics for PF.
But who has the expertise to design custom orthotics? I find this very confusing. We had patients at Bayshore who had a bag full of orthotics, costing thousands of dollars and (according to them) of very little use. The various sources they have tried ranged from podiatrists, chiropodists, chiropractors, physiotherapists to pharmacists who provide computer-designed orthotics in the local pharmacy and anyone else who becomes a 'specialist'.
I am surprised that this is not regulated like in Europe where such items are prescribed only by specialists with years of education and training.
Can someone answer who is a specialist for orthotics and what of type of training they have and how long?

Re: Orthotics for feet

Pete R on 7/22/02 at 12:57 (090351)

Living in England I can tell you that there are no regulations regarding the production of orthotics. I'm on my 6th pair, the previous ones have been made by a selection of chiropractors, pods etc, most of whom have no understanding of really what they're doing i.e One person tried to covince me that 'filling the gap' under my arch would alleviate my heel pain !

Many practioners here see it as a way of making 'easy' money at the expense of us sufferers, as can be seen by the variety of retailers who now stock foot products / orthotics compared to when I first had problems 3 years ago.

The big problem here is differentiating between pods and chirpodists, 90% of who's knowledge is limited to treating in growing toe nails rather than understanding bio mechanics of the foot / leg.

Frustrating for all........except the retailers / practitioners !

Re: Orthotics for feet

Sunny Jacob - Bayshore on 7/22/02 at 20:28 (090385)

Thank you for the response from England. I wanted to initiate this discussion as the matter of orthotics is completely unclear to me.
Today I was passing a chiropractor's practice near Toronto, Canada. The list of services provided was on the clinic front. It included over 30 services, including orthotics for feet. Unsuspecting, hopeful clients I am certain, will also get those orthotics for several hundreds of dollars at that clinic. I wonder where a chiropractor gets his or her training to make custom orthotics.
One country I know well is Germany.In contrast to England (as you have mentioned), orthotics design and custom fitting is a profession and this is the only thing they practice.
In this connection I find it interesting that approx. 60% of tendinopathies treated with ESWT in North America are patients suffering from Plantar fasciitis. In Germany, approx. 60% of patients treated in the about 20 ESWT clinics I know of have shoulder tendonitis or bursitis.
I wonder why?

Re: Orthotics for feet

john h on 7/23/02 at 09:55 (090425)

Sunny: One of he most successful sellers of orthotics in the U.S. is the Good Feet Store. They advertise heavily, do infomercials, and locate in shopping centers. The claim to be custom fit to your feet but in fact you walk in and walk out with orthotics that came off the shelf at a cost of $200 and up. The sales people are probably put through a few hours of training and that is it. On the other side of the coin there is a maker of custom orthotics in town who requires a prescription from a Doctor. These folks are highly tranined in the making of of prosthetic and orthotics. I think this is an unreglulated industry compared to Europe.

Re: Orthotics for feet

Ed Davis, DPM on 7/24/02 at 16:02 (090509)

Sunny:

It is probably unfortunate that the US lacks regulations concerning how and who makes orthotics. I am not fond of excess government interference with free enterprise but do believe in basic protections.

Podiatric physicians have the most intensive curriculum of any provider when it comes to biomechanics of the lower extremity and orthotic production. Pedorthists are a newer profession and would probably rank second in this area.

The advent of 'computer designed' orthotics has been both a blessing and a curse. Automation and the ease of production that the process introduces may, when the process has been perfected, facilitate the fitting and production process. The downside is that a number of minimally trained individuals have used the banner of 'computerized foot orthotics' to set up shop, becoming self-proclaimed 'experts' overnight.
Ed

Re: Orthotics for feet

Pauline on 7/24/02 at 16:34 (090517)

John,
Good for who should be the question purchasers ask. As you know there have been many posts about the 'Good foot Stores'. The orthotics out last their salepeople. That's about the best thing you can say about these folks.

Re: Orthotics for feet

Pauline on 7/24/02 at 16:45 (090519)

Question Dr. Davis. Just about everyone is now using 'computerized foot
Orthotics'. The computer doesn't know if a doctor or a salesman is entering the information. It spits out the same information based on the reading it takes from the feet. Each person puts the foot in position based on what the computer is asking so why should the results be different?

Now if the doctor is using a casting method, I can possibly see different results based on the doctors personal work, but by computer it seems like results would be the same no matter who enters the information. Less room for error and the computer is telling you what to enter.

Re: Orthotics for feet

john h on 7/25/02 at 08:26 (090549)

Pauline: I have wearing the Footmax computer generated orthotics for about 2 years. They are semi rigid and I have had two adjustments made to them. I like them better than two pair of custom made orthotics or any of the zillions of over the counter types I have purchased. They still are not as good as birks but when I have to wear shoes they do ok.

Re: Orthotics for feet

Ed Davis, DPM on 7/25/02 at 19:32 (090607)

Pauline:

You are not correct in stating that 'just about everyone is using computerized foot orthotics.' I know very few qualified professionals that do.

It is not the computer that 'reads' the information about the foot. Some type of device must be used for input. That device could be an optical scanner, a pressure sensitive mat or similar device.

Lets take the example of a pressure mat. I can walk across a pressure mat, hitting the mat differently each time therby causing different results. Only a pressure mat system that can record multiple steps and average the results can produce anything close to an accurate picture of what is going on. There is no such system that I know of being used on a regular basis. There is also a controversy as to whether a pressure sensitive mat, which basically recieves two dimensional information can achieve an accurate image of a three dimensional object, ie. the foot.

Next, lets look at optical scanners. An optical scanner can obtain a good 3 dimensional image of the foot. But, what position of the foot should be captured? Do we capture the foot in, say, its deformed pronated position?
How are corrections made? How does one relate the shape of the foot, if that is all that is captured to function of the foot? Shape and function can be very different.

There is no computer program that specifies what position the foot is to be placed in to capture the best functional image. There is no computer program that can perform a biomechanical exam of the foot and apply that data to creation of an orthotic. No computer can tell the examiner what to enter.
Ed

Re: Orthotics for feet

Pauline on 7/26/02 at 10:03 (090650)

Dr. Davis,
Your post magnifies the difficulty for patients to get a good fitting, wearable orthotic. With so many variables regardless of the method in use is it any wonder why many of us have bags filled with orthotics that we could not use.

Re: Orthotics for feet

john h on 7/26/02 at 12:54 (090674)

Dr.Ed I agree with you about the mat even though that is what I used to have my Footmax orthotics made from. My question is this: If you cast a foot in any position (standing lying down,etc) you are just taking a snapshot of the moment. The same thing happens with an MRI for a back problem. What is needed is a dynamic look at the feet in motion or the back in motion to accurately see what is going on in the real working world of the feet,back,etc. I do not think the technology exist to accurately view the dynamics of the feet in motion so as to design precise orthotics. We are operating with a hit or miss system that works for some and may even make others worse. A foot at rest is sure not like a foot in motion with weight on it.

Re: Orthotics for feet

Ed Davis, DPM on 7/26/02 at 13:23 (090677)

John:

You are correct when you state that there is no technology in common usage that can obtain accurate dynamic data and apply it properly. Nevertheless, podiatric physicians are trained to do so visually via gait analysis and the biomechanical exam. We often are hurried and cut that portion of the process too short!
Ed

Re: Orthotics for feet

john h on 7/26/02 at 14:46 (090690)

Dr Ed: Over the past 8 years I have been to many many MD's and Podiatrist and no one has ever asked to observe my walk. The only guy to ever do that was at my local running shoe store where he had me run around for about 5 minutes to determine if I was pronating or what.

Re: Orthotics for feet

Pauline on 7/26/02 at 15:27 (090699)

John,
Every Physical Therapist I've had for P.F. observed my walk. So did the Ortho. I think they like to watch the limp. You were probably watched when you went for your x-ray's but you just didn't know it.

Re: Orthotics for feet

john h on 7/26/02 at 18:44 (090709)

Pauline: the girls who usually take me to x-ray were not interested in my walk.

Re: Orthotics for feet

Ed Davis, DPM on 7/27/02 at 13:00 (090743)

John:

That is really sad to see practitioners short-cutting the exam.
Ed

Re: Orthotics for feet

john h on 7/27/02 at 17:08 (090760)

Dr. Ed: I cannot believe how unbelievable inexpensive EWST is in Australia. I think Allan (Very very knowledable technician who performs ESWT) told me that the EPOS treatements are $50 each with a three treatment protocol. How can this be?

Re: do we really need dynamics?

elliott on 7/27/02 at 23:28 (090781)

Orthotics seem to work for a lot of people, even though they had their mold taken statically. Furthermore, without orthotics the patient likely is walking incorrectly (possibly even aside from biomechanics, e.g. due to pain), limiting the analysis of gait contribution even if it were feasible, but which the statically-produced orthotic might correct.

---

Re: Orthotics for feet

Sunny Jacob - Bayshore on 7/28/02 at 09:02 (090788)

John,
$150 for three sessions? This is diffcult to comprehend based on normal financial principles.
- Assuming they got an approx. $200,000 equipment free
- Specialists' or technicians' time free
- all overhead costs such as space, liability insurance, preventive maintenance free
The replacement of EMSE (electromagnetic shock wave emitter) alone after every 1 million shocks*(i.e. 6,000 shocks per patient for 166 patients)alone is $10,000.--(parts and labour), i.e. $60 per patient.
* life expectancy of EMSE

Re: Orthotics for feet

Don.S on 7/28/02 at 23:58 (090874)

Alan may say $50 per session, but the Australian Dollar has nowhere the value of the $USD. The exchange rate is down and is only worth about 50% at the moment
Don

Re: do we really need dynamics?

Ed Davis, DPM on 7/29/02 at 12:39 (090903)

Elliott:

The more complete the information used in making the orthotic the greater the chance of success. Keep in mind that there is a standard of care that basically requires that a reasonable amount of biomechanical information go into the making of orthotics. There are way too many unsuccessful orthotics out there-- just read this site to see lots of examples. Even a 'perfectly' made orthotic will not be effective all the time. Patients need to know what standard was used in making their device, what they (or their insurer) is really paying for. If orthotics do not work, then patients need to know if it was orthotic therapy per se or an inadequate pair of orthotics.
Ed

Re: Orthotics for feet

john h on 7/29/02 at 17:40 (090929)

I am going to email Allan and ask him if they own the machines which I expect they do. Allan travels a large area with the machine. He of course is under the guidance of a group of Poditrist (I think). He has even been to Singapore to provide treatment. I bet the cost of the machines varies considerable from country to country.

Re: Orthotics for feet

Joe S on 7/31/02 at 00:01 (091070)

And many people wonder why these 300 dollar arch supports don't work. You know I have my patient's walk all the time. We have a hallway that is about 100 feet long. We have 15 treatment rooms lined up down this hallway. I can get a pretty accurate view of their gait pattern this way. When it comes to casting a patient for orthotics, you can mimick the weightbearing attitude by loading the foot. One reason I think alot of practitioners fail with orthotic therapy is that they only use one specific orthotic shell for all conditions. I mean, not to insult anyone here, but if a lady who is 5'4 and weighs 250 lbs with PF comes in and need biomechanical support and states that she has to wear dress flats or pumps to work and needs an a thinline dress orthotic to work in her shoes. She is one of the ones that would probably fail orthotic therapy. We had a company recently come and take all of the local pods out and basically tell us that if we use their orthotics they would waive shipping charges or whatever. That's fine but there is a downside. I don't really care about their shipping charges. If I cast a person for a pair of orthotics which are not typically covered by an insurance company, then I want to get exactly what the patient needs. Personally, I would not want to pay upwards of 300 dollars for a product which may be inferior. I use all of the major labs. I've even used a couple of local labs. There is a big difference in quality from lab to lab. Also, the negative cast which is made is very critical in getting a good orthotic as well. As Dr. Ed said, a thorough biomechanical exam is needed. This includes both static weightbearing and nonweightbearing measurements as well as a gait exam. Anything short of this and the failure rate increases drastically. This would be an interesting study. Have two subsets of patients with heel pain (biomechanically induced) and have them casted for orthotics in four fashions (Foam Box without a biomechanical exam, foam box with biomechanical exam, plaster without biomechanical exam, and plaster with biomechanical exam). I wonder what the outcome would be. My point is that the biomechanical exam helps you in writing the prescription to the lab for the appropriate adjustments instead of just marking 'according to the cast'. Anyway, another longwinded post.

Re: Orthotics for feet

Pauline on 7/31/02 at 08:04 (091107)

Well Dr. Joe if the profession knows the failure rate for orthotics and patients are still getting stuck with 'ice scrapers' that they cannot wear and continue to loose $200 + with each try isn't it time for some changes
and refunds on these Rx products?

Personally, I think it's long overdue. The failure rate could be the reason most insurance companies won't pay for orthotics.

A patient in pain is willing to try anything to get relief. The suggestion, and sometimes promise that orthotics will help makes the patient more than willing to go along with the idea and shell out the money.

If orthotics don't produce results the patients money should be returned. Perhaps a service fee should be charged, but the bulk of the money should be refunded.

This area of Podiatry also needs to be fixed. Why should patients continue to be stuck with empty promises?

Re: Orthotics for feet

john h on 7/31/02 at 10:03 (091129)

Joe: I would gladly pay $500 or more for orthotics if they provided sufficient relief. Most of us complain because we have bought 3 or more pair of high priced orthotics and not only have obtained no relief but in some cases made worse. I am currently wearing the Footmax which I think is made in Canada and I do think it has been the best of the lot and does help. Not as good as Birk sandals but worth the $400. I have the local lab who ordered them make two adjustments for me which they gladly did for free. I had them take down the arch area slightly in both cases so I did not have as much pressure on the fascia where it inserts into the heel on the inside of the foot.My first ever pair of orthotics were Sportsthotics which I understand is a well respected manufacturer. They were rigid and I ran in them until PF brought me to a halt.One of the ladies on the board quit wearing orthotics last year and from her mail to me she is much better. This is not to suggest that orthotics do not help thousands of people as I recognize they do.

Re: Orthotics for feet

john h on 7/31/02 at 10:10 (091133)

My personal feeling is orthotics are needed by some people but are greatly over sold to increase revenue.

Re: Orthotics for feet

Joe S on 7/31/02 at 12:59 (091151)

I don't think the public is being filled with empty promises. You heard of the Good Feet store, The Alznner Orthotic... Those are empty promises. They don't refund your money either. My post was about prescribing the right orthosis for the right person. Alot (not al) of practitioners use only one orthotic for everything. They are made different. Different conditions require different orthoses. Some people do well with over the counter prefabs others don't. One reason that most people fail with orthotc therapy is that THEY DON'T WEAR THEM. I see it day in and day out. Patient comes in for follow up heel pain that hasd been prescribed orthotics and I ask where are the orthotics...I decided to not wear them today because I was coming here...I'm sure the other docs hear this too frequently as well.

Re: Orthotics for feet

Joe S on 7/31/02 at 13:00 (091152)

Very little revenue comes from orthotics unless someone is charging 450 dollars a pop. I charge 250 and that basically covers the orthotic, the casting, and the two appointments for follow up. Not much revenue being generated in my office.

Re: Orthotics for feet

john h on 7/31/02 at 16:08 (091178)

$400 is the going rate around Little Rock Joe.

Re: Orthotics for feet

Carole C in NOLA on 7/31/02 at 19:07 (091204)

Sometimes I wonder if the reason some people have trouble with orthotics is that they are on their feet too much, and their feet 'reject' the orthotic. Maybe if they chose copious rest, especially at first, their orthotics would 'take' and help to heal them.

If my recollection is correct, John, you and I have differing views on the value of lots of rest in PF. It could be that one modality of 'cure' is to combine lots of rest and soft custom orthotics, which is what I did (along with many other conventional treatments). But there are so many different ways to skin a cat, and perhaps you have followed another path.

I really felt that my soft custom orthotics made a huge difference for me.

Carole C

Re: Orthotics for feet

john h on 7/31/02 at 19:11 (091206)

Carole: I do not profess to know what rest does in the long term for PF. I certainly know that sometimes your feet hurt so bad that rest is not an option but a must. I do think that one can not give in and decide that rest must become a way of life. Of course, we must define rest to have any sort of meaningful debate. We may actually be in agreement and not know it.

Re: Orthotics for feet

Carole C in NOLA on 7/31/02 at 19:55 (091213)

We might be in agreement, as you said.

For me, resting more than a lot of people was a big help when my PF was really bad with pain of about an 8 on a scale of 1 to 10. But even then, gentle stretching and very very gentle wiggling of my toes was part of my 'rest', as was a little self-massage of my feet. I didn't keep my feet or ankles completely immobile; I just didn't stand up on my feet very much and I didn't do anything that hurt.

During this period of time, when my pain was the greatest, my orthotics helped the most. I did have to stand sometimes in order to use the rest room, and to walk a few feet to get in my car and go to work. With the orthotics I could do this sort of thing and the orthotics seemed to protect my feet from further damage to some extent when I did. They were very thick and cushioned, and yet firmly positioned my feet in such a way that there could not be much strain on my plantar fascia.

As my feet got better, it seemed reasonable to challenge them more and more, bearing in mind that increased activity seemed to work best if I did less than I thought I could do, rather than more.

By the time my pain level was down to about a 2 on a scale of 1-10, I was able to walk a whole lot more (even though I walked less than I thought I could). All that additional walking caused the orthotic to rub blisters in my arches and even when I didn't wear them I didn't feel that moderate walking was injuring my feet. My feet had grown stronger and were harder to injure. So, I stopped wearing my orthotics (OK, vanity was involved here too, but vanity didn't matter at all when I was in more pain).

What I found amazing was that as I emerged from my near constant rest stage to this stage of moving around more, it didn't take me nearly as long as I thought to re-build the muscles in my feet (which were pretty wimpy at first after all that rest). I wiggled my toes and feet more and more, and exercised my foot muscles slowly and carefully, over a couple of weeks, and along with that I gradually increased how much I walked and that took care of most of it.

Like you, I don't know what rest does in the long term for PF. For me, maximum rest during December, January, and February really helped. By March, I was moving around more and not wearing my orthotics. I really do think that my rapid improvement in February was due to not re-injuring my feet for more than a month, and this in turn was due mainly to rest and custom orthotics, combined with the rest of what we learn here. I did re-injure them repeatedly in December and sometimes in January, because I was still learning and making too many mistakes.

Carole C

Re: Orthotics for feet

Joe S on 7/31/02 at 23:42 (091229)

wow. That's pricey. We charge 250 in and out the door and that includes a plaster cast.

Re: Orthotics for feet

Joe S on 8/04/02 at 22:18 (091586)

Footmax are not custom orthotics. They match your foot to an orthotic shell. They are customized for you but are not custom. The only way to get a rtue custom orthotic is to have a molded cast of your foot with an orthotic built around that cast. Adjustments can be made to the positive cast according to measurements taken during the hands on biomechanical exam.

Re: Orthotics for feet

john h on 8/05/02 at 13:36 (091644)

Dr.Joe: picky picky picky! I pay $400 for othotics and now you tell me they are not custom. Are they not custom in that only my feet could generate the exact computer impressions on that mat? No others feet will produce my excact computer generated impression. Well, anyway having had two sets that would qualify as custom I am more happy with these than my Sportsthotics (casted) and the other custom soft orthotic made from a foot impression in a box.

Re: Orthotics for feet

BG CPed on 8/05/02 at 18:34 (091672)

Well the Footmax are not custom. They should be called custom fit perhaps but they are not custom in the true sense. They use a statis mat and have you walk over it. This gives a crude topograph or cast like image. If a person has a hypermobile foot that overpronates then taking a 'snapshot' of the foot in that poor position is a bit flawed, much like taking an eye exam while you squint a bit.

Thjat info is sent to Canada where the techs will look at the colors e.g. elevations and shapes. Techs then pick out the closetst shell from a selection of pre-made shells. There is never an actual positive mold made and no milling is done either so they are modified pre mades.

I am not trying to flame here and if the devices work and they are made from an old frisbee and cost $600 then they are worth it, that said the wholesale and ultimately retail cost for them is expensive for what is actually done. You could fill a cookie pan with kitty litter, walk through it, fill it with plaster and have a similar result.

The points about giving refunds has two sides. Orthotic therapy can be very effective, it can also fail in some cases. Failures depend on many factors and PT compliance is one aspect. Skill level or lack thereof on the Practitioners part is also a factor. I give both verbal and writen instructions. I also measure the pt feet both arch and heel toe as well as go over proper footwear.

As much as I dislike the Gov I would welcome an orthotics certification board that would cover all practitioners. There are too many slimey types in the business as well as folks with good intentions just lacking the skills and tools to do a proper job.

I have had my share of failed orthotics but I have had many morepostive results. I dont think anybody gets a refund when your Stockbroker, Lawyer or Teacher does not 'fix' the problem or get 100% results. If you get a reaction from say Celebrex and break out in hives after 3 days, you dont return it to pharmacy for a refund. It was givin to hopefully relieve symptoms, as it does in many thousands. Unfortunatly it doesnt have a 100% success rate.

I only charge $175 a pair and do them in an hour. Because of insurance company nonsense I dont accept any insurance and only will bill for work comp or auto.

I used to charge $175 for auto thinking I was being nice and I would get taken care of since my competitors charge $350 plus. The last straw was from State Farm dragging out a claim that they originally approved and it took over 6 months to collect after tons of paperwork and calls. Now they all get charged what my competitors charge. Since I dont participate in medicare/medicaide I can do that. Many pt have no idea what extra crap you can be subject to when doing billing, just ask a medical biller I think they rank up with air traffic controllers.

Re: Orthotics for feet

Joe S on 8/08/02 at 20:27 (092021)

We charge 250 for orthotics made from a neutral position cast. At least yuo didn't pay 250 or whatever they cost for the alznners. Footmaxx does not make true custom functional orthotics. They take your measurements from their static gait mat that you walk across three times and from those three computer generated pressure analyses, they choose an appropriate shell for you. Customization can then be performed. I personally don't have a problem with footmax or their products. I've used them before. I also don't believe every single person with heel pain needs a custom orthotic. Many people can be effectively treated with an over the counter prefab. I do like the footmax orthotics for diabetics though. I like the fact that I can see where their weight is being distributed after an amputation. From that we can make an accommodative orthotic to help offload the high pressure areas.

Re: Orthotics for feet

Joe S on 8/08/02 at 20:30 (092022)

Very well stated.

Re: Orthotics for feet

Pete R on 7/22/02 at 12:57 (090351)

Living in England I can tell you that there are no regulations regarding the production of orthotics. I'm on my 6th pair, the previous ones have been made by a selection of chiropractors, pods etc, most of whom have no understanding of really what they're doing i.e One person tried to covince me that 'filling the gap' under my arch would alleviate my heel pain !

Many practioners here see it as a way of making 'easy' money at the expense of us sufferers, as can be seen by the variety of retailers who now stock foot products / orthotics compared to when I first had problems 3 years ago.

The big problem here is differentiating between pods and chirpodists, 90% of who's knowledge is limited to treating in growing toe nails rather than understanding bio mechanics of the foot / leg.

Frustrating for all........except the retailers / practitioners !

Re: Orthotics for feet

Sunny Jacob - Bayshore on 7/22/02 at 20:28 (090385)

Thank you for the response from England. I wanted to initiate this discussion as the matter of orthotics is completely unclear to me.
Today I was passing a chiropractor's practice near Toronto, Canada. The list of services provided was on the clinic front. It included over 30 services, including orthotics for feet. Unsuspecting, hopeful clients I am certain, will also get those orthotics for several hundreds of dollars at that clinic. I wonder where a chiropractor gets his or her training to make custom orthotics.
One country I know well is Germany.In contrast to England (as you have mentioned), orthotics design and custom fitting is a profession and this is the only thing they practice.
In this connection I find it interesting that approx. 60% of tendinopathies treated with ESWT in North America are patients suffering from Plantar fasciitis. In Germany, approx. 60% of patients treated in the about 20 ESWT clinics I know of have shoulder tendonitis or bursitis.
I wonder why?

Re: Orthotics for feet

john h on 7/23/02 at 09:55 (090425)

Sunny: One of he most successful sellers of orthotics in the U.S. is the Good Feet Store. They advertise heavily, do infomercials, and locate in shopping centers. The claim to be custom fit to your feet but in fact you walk in and walk out with orthotics that came off the shelf at a cost of $200 and up. The sales people are probably put through a few hours of training and that is it. On the other side of the coin there is a maker of custom orthotics in town who requires a prescription from a Doctor. These folks are highly tranined in the making of of prosthetic and orthotics. I think this is an unreglulated industry compared to Europe.

Re: Orthotics for feet

Ed Davis, DPM on 7/24/02 at 16:02 (090509)

Sunny:

It is probably unfortunate that the US lacks regulations concerning how and who makes orthotics. I am not fond of excess government interference with free enterprise but do believe in basic protections.

Podiatric physicians have the most intensive curriculum of any provider when it comes to biomechanics of the lower extremity and orthotic production. Pedorthists are a newer profession and would probably rank second in this area.

The advent of 'computer designed' orthotics has been both a blessing and a curse. Automation and the ease of production that the process introduces may, when the process has been perfected, facilitate the fitting and production process. The downside is that a number of minimally trained individuals have used the banner of 'computerized foot orthotics' to set up shop, becoming self-proclaimed 'experts' overnight.
Ed

Re: Orthotics for feet

Pauline on 7/24/02 at 16:34 (090517)

John,
Good for who should be the question purchasers ask. As you know there have been many posts about the 'Good foot Stores'. The orthotics out last their salepeople. That's about the best thing you can say about these folks.

Re: Orthotics for feet

Pauline on 7/24/02 at 16:45 (090519)

Question Dr. Davis. Just about everyone is now using 'computerized foot
Orthotics'. The computer doesn't know if a doctor or a salesman is entering the information. It spits out the same information based on the reading it takes from the feet. Each person puts the foot in position based on what the computer is asking so why should the results be different?

Now if the doctor is using a casting method, I can possibly see different results based on the doctors personal work, but by computer it seems like results would be the same no matter who enters the information. Less room for error and the computer is telling you what to enter.

Re: Orthotics for feet

john h on 7/25/02 at 08:26 (090549)

Pauline: I have wearing the Footmax computer generated orthotics for about 2 years. They are semi rigid and I have had two adjustments made to them. I like them better than two pair of custom made orthotics or any of the zillions of over the counter types I have purchased. They still are not as good as birks but when I have to wear shoes they do ok.

Re: Orthotics for feet

Ed Davis, DPM on 7/25/02 at 19:32 (090607)

Pauline:

You are not correct in stating that 'just about everyone is using computerized foot orthotics.' I know very few qualified professionals that do.

It is not the computer that 'reads' the information about the foot. Some type of device must be used for input. That device could be an optical scanner, a pressure sensitive mat or similar device.

Lets take the example of a pressure mat. I can walk across a pressure mat, hitting the mat differently each time therby causing different results. Only a pressure mat system that can record multiple steps and average the results can produce anything close to an accurate picture of what is going on. There is no such system that I know of being used on a regular basis. There is also a controversy as to whether a pressure sensitive mat, which basically recieves two dimensional information can achieve an accurate image of a three dimensional object, ie. the foot.

Next, lets look at optical scanners. An optical scanner can obtain a good 3 dimensional image of the foot. But, what position of the foot should be captured? Do we capture the foot in, say, its deformed pronated position?
How are corrections made? How does one relate the shape of the foot, if that is all that is captured to function of the foot? Shape and function can be very different.

There is no computer program that specifies what position the foot is to be placed in to capture the best functional image. There is no computer program that can perform a biomechanical exam of the foot and apply that data to creation of an orthotic. No computer can tell the examiner what to enter.
Ed

Re: Orthotics for feet

Pauline on 7/26/02 at 10:03 (090650)

Dr. Davis,
Your post magnifies the difficulty for patients to get a good fitting, wearable orthotic. With so many variables regardless of the method in use is it any wonder why many of us have bags filled with orthotics that we could not use.

Re: Orthotics for feet

john h on 7/26/02 at 12:54 (090674)

Dr.Ed I agree with you about the mat even though that is what I used to have my Footmax orthotics made from. My question is this: If you cast a foot in any position (standing lying down,etc) you are just taking a snapshot of the moment. The same thing happens with an MRI for a back problem. What is needed is a dynamic look at the feet in motion or the back in motion to accurately see what is going on in the real working world of the feet,back,etc. I do not think the technology exist to accurately view the dynamics of the feet in motion so as to design precise orthotics. We are operating with a hit or miss system that works for some and may even make others worse. A foot at rest is sure not like a foot in motion with weight on it.

Re: Orthotics for feet

Ed Davis, DPM on 7/26/02 at 13:23 (090677)

John:

You are correct when you state that there is no technology in common usage that can obtain accurate dynamic data and apply it properly. Nevertheless, podiatric physicians are trained to do so visually via gait analysis and the biomechanical exam. We often are hurried and cut that portion of the process too short!
Ed

Re: Orthotics for feet

john h on 7/26/02 at 14:46 (090690)

Dr Ed: Over the past 8 years I have been to many many MD's and Podiatrist and no one has ever asked to observe my walk. The only guy to ever do that was at my local running shoe store where he had me run around for about 5 minutes to determine if I was pronating or what.

Re: Orthotics for feet

Pauline on 7/26/02 at 15:27 (090699)

John,
Every Physical Therapist I've had for P.F. observed my walk. So did the Ortho. I think they like to watch the limp. You were probably watched when you went for your x-ray's but you just didn't know it.

Re: Orthotics for feet

john h on 7/26/02 at 18:44 (090709)

Pauline: the girls who usually take me to x-ray were not interested in my walk.

Re: Orthotics for feet

Ed Davis, DPM on 7/27/02 at 13:00 (090743)

John:

That is really sad to see practitioners short-cutting the exam.
Ed

Re: Orthotics for feet

john h on 7/27/02 at 17:08 (090760)

Dr. Ed: I cannot believe how unbelievable inexpensive EWST is in Australia. I think Allan (Very very knowledable technician who performs ESWT) told me that the EPOS treatements are $50 each with a three treatment protocol. How can this be?

Re: do we really need dynamics?

elliott on 7/27/02 at 23:28 (090781)

Orthotics seem to work for a lot of people, even though they had their mold taken statically. Furthermore, without orthotics the patient likely is walking incorrectly (possibly even aside from biomechanics, e.g. due to pain), limiting the analysis of gait contribution even if it were feasible, but which the statically-produced orthotic might correct.

---

Re: Orthotics for feet

Sunny Jacob - Bayshore on 7/28/02 at 09:02 (090788)

John,
$150 for three sessions? This is diffcult to comprehend based on normal financial principles.
- Assuming they got an approx. $200,000 equipment free
- Specialists' or technicians' time free
- all overhead costs such as space, liability insurance, preventive maintenance free
The replacement of EMSE (electromagnetic shock wave emitter) alone after every 1 million shocks*(i.e. 6,000 shocks per patient for 166 patients)alone is $10,000.--(parts and labour), i.e. $60 per patient.
* life expectancy of EMSE

Re: Orthotics for feet

Don.S on 7/28/02 at 23:58 (090874)

Alan may say $50 per session, but the Australian Dollar has nowhere the value of the $USD. The exchange rate is down and is only worth about 50% at the moment
Don

Re: do we really need dynamics?

Ed Davis, DPM on 7/29/02 at 12:39 (090903)

Elliott:

The more complete the information used in making the orthotic the greater the chance of success. Keep in mind that there is a standard of care that basically requires that a reasonable amount of biomechanical information go into the making of orthotics. There are way too many unsuccessful orthotics out there-- just read this site to see lots of examples. Even a 'perfectly' made orthotic will not be effective all the time. Patients need to know what standard was used in making their device, what they (or their insurer) is really paying for. If orthotics do not work, then patients need to know if it was orthotic therapy per se or an inadequate pair of orthotics.
Ed

Re: Orthotics for feet

john h on 7/29/02 at 17:40 (090929)

I am going to email Allan and ask him if they own the machines which I expect they do. Allan travels a large area with the machine. He of course is under the guidance of a group of Poditrist (I think). He has even been to Singapore to provide treatment. I bet the cost of the machines varies considerable from country to country.

Re: Orthotics for feet

Joe S on 7/31/02 at 00:01 (091070)

And many people wonder why these 300 dollar arch supports don't work. You know I have my patient's walk all the time. We have a hallway that is about 100 feet long. We have 15 treatment rooms lined up down this hallway. I can get a pretty accurate view of their gait pattern this way. When it comes to casting a patient for orthotics, you can mimick the weightbearing attitude by loading the foot. One reason I think alot of practitioners fail with orthotic therapy is that they only use one specific orthotic shell for all conditions. I mean, not to insult anyone here, but if a lady who is 5'4 and weighs 250 lbs with PF comes in and need biomechanical support and states that she has to wear dress flats or pumps to work and needs an a thinline dress orthotic to work in her shoes. She is one of the ones that would probably fail orthotic therapy. We had a company recently come and take all of the local pods out and basically tell us that if we use their orthotics they would waive shipping charges or whatever. That's fine but there is a downside. I don't really care about their shipping charges. If I cast a person for a pair of orthotics which are not typically covered by an insurance company, then I want to get exactly what the patient needs. Personally, I would not want to pay upwards of 300 dollars for a product which may be inferior. I use all of the major labs. I've even used a couple of local labs. There is a big difference in quality from lab to lab. Also, the negative cast which is made is very critical in getting a good orthotic as well. As Dr. Ed said, a thorough biomechanical exam is needed. This includes both static weightbearing and nonweightbearing measurements as well as a gait exam. Anything short of this and the failure rate increases drastically. This would be an interesting study. Have two subsets of patients with heel pain (biomechanically induced) and have them casted for orthotics in four fashions (Foam Box without a biomechanical exam, foam box with biomechanical exam, plaster without biomechanical exam, and plaster with biomechanical exam). I wonder what the outcome would be. My point is that the biomechanical exam helps you in writing the prescription to the lab for the appropriate adjustments instead of just marking 'according to the cast'. Anyway, another longwinded post.

Re: Orthotics for feet

Pauline on 7/31/02 at 08:04 (091107)

Well Dr. Joe if the profession knows the failure rate for orthotics and patients are still getting stuck with 'ice scrapers' that they cannot wear and continue to loose $200 + with each try isn't it time for some changes
and refunds on these Rx products?

Personally, I think it's long overdue. The failure rate could be the reason most insurance companies won't pay for orthotics.

A patient in pain is willing to try anything to get relief. The suggestion, and sometimes promise that orthotics will help makes the patient more than willing to go along with the idea and shell out the money.

If orthotics don't produce results the patients money should be returned. Perhaps a service fee should be charged, but the bulk of the money should be refunded.

This area of Podiatry also needs to be fixed. Why should patients continue to be stuck with empty promises?

Re: Orthotics for feet

john h on 7/31/02 at 10:03 (091129)

Joe: I would gladly pay $500 or more for orthotics if they provided sufficient relief. Most of us complain because we have bought 3 or more pair of high priced orthotics and not only have obtained no relief but in some cases made worse. I am currently wearing the Footmax which I think is made in Canada and I do think it has been the best of the lot and does help. Not as good as Birk sandals but worth the $400. I have the local lab who ordered them make two adjustments for me which they gladly did for free. I had them take down the arch area slightly in both cases so I did not have as much pressure on the fascia where it inserts into the heel on the inside of the foot.My first ever pair of orthotics were Sportsthotics which I understand is a well respected manufacturer. They were rigid and I ran in them until PF brought me to a halt.One of the ladies on the board quit wearing orthotics last year and from her mail to me she is much better. This is not to suggest that orthotics do not help thousands of people as I recognize they do.

Re: Orthotics for feet

john h on 7/31/02 at 10:10 (091133)

My personal feeling is orthotics are needed by some people but are greatly over sold to increase revenue.

Re: Orthotics for feet

Joe S on 7/31/02 at 12:59 (091151)

I don't think the public is being filled with empty promises. You heard of the Good Feet store, The Alznner Orthotic... Those are empty promises. They don't refund your money either. My post was about prescribing the right orthosis for the right person. Alot (not al) of practitioners use only one orthotic for everything. They are made different. Different conditions require different orthoses. Some people do well with over the counter prefabs others don't. One reason that most people fail with orthotc therapy is that THEY DON'T WEAR THEM. I see it day in and day out. Patient comes in for follow up heel pain that hasd been prescribed orthotics and I ask where are the orthotics...I decided to not wear them today because I was coming here...I'm sure the other docs hear this too frequently as well.

Re: Orthotics for feet

Joe S on 7/31/02 at 13:00 (091152)

Very little revenue comes from orthotics unless someone is charging 450 dollars a pop. I charge 250 and that basically covers the orthotic, the casting, and the two appointments for follow up. Not much revenue being generated in my office.

Re: Orthotics for feet

john h on 7/31/02 at 16:08 (091178)

$400 is the going rate around Little Rock Joe.

Re: Orthotics for feet

Carole C in NOLA on 7/31/02 at 19:07 (091204)

Sometimes I wonder if the reason some people have trouble with orthotics is that they are on their feet too much, and their feet 'reject' the orthotic. Maybe if they chose copious rest, especially at first, their orthotics would 'take' and help to heal them.

If my recollection is correct, John, you and I have differing views on the value of lots of rest in PF. It could be that one modality of 'cure' is to combine lots of rest and soft custom orthotics, which is what I did (along with many other conventional treatments). But there are so many different ways to skin a cat, and perhaps you have followed another path.

I really felt that my soft custom orthotics made a huge difference for me.

Carole C

Re: Orthotics for feet

john h on 7/31/02 at 19:11 (091206)

Carole: I do not profess to know what rest does in the long term for PF. I certainly know that sometimes your feet hurt so bad that rest is not an option but a must. I do think that one can not give in and decide that rest must become a way of life. Of course, we must define rest to have any sort of meaningful debate. We may actually be in agreement and not know it.

Re: Orthotics for feet

Carole C in NOLA on 7/31/02 at 19:55 (091213)

We might be in agreement, as you said.

For me, resting more than a lot of people was a big help when my PF was really bad with pain of about an 8 on a scale of 1 to 10. But even then, gentle stretching and very very gentle wiggling of my toes was part of my 'rest', as was a little self-massage of my feet. I didn't keep my feet or ankles completely immobile; I just didn't stand up on my feet very much and I didn't do anything that hurt.

During this period of time, when my pain was the greatest, my orthotics helped the most. I did have to stand sometimes in order to use the rest room, and to walk a few feet to get in my car and go to work. With the orthotics I could do this sort of thing and the orthotics seemed to protect my feet from further damage to some extent when I did. They were very thick and cushioned, and yet firmly positioned my feet in such a way that there could not be much strain on my plantar fascia.

As my feet got better, it seemed reasonable to challenge them more and more, bearing in mind that increased activity seemed to work best if I did less than I thought I could do, rather than more.

By the time my pain level was down to about a 2 on a scale of 1-10, I was able to walk a whole lot more (even though I walked less than I thought I could). All that additional walking caused the orthotic to rub blisters in my arches and even when I didn't wear them I didn't feel that moderate walking was injuring my feet. My feet had grown stronger and were harder to injure. So, I stopped wearing my orthotics (OK, vanity was involved here too, but vanity didn't matter at all when I was in more pain).

What I found amazing was that as I emerged from my near constant rest stage to this stage of moving around more, it didn't take me nearly as long as I thought to re-build the muscles in my feet (which were pretty wimpy at first after all that rest). I wiggled my toes and feet more and more, and exercised my foot muscles slowly and carefully, over a couple of weeks, and along with that I gradually increased how much I walked and that took care of most of it.

Like you, I don't know what rest does in the long term for PF. For me, maximum rest during December, January, and February really helped. By March, I was moving around more and not wearing my orthotics. I really do think that my rapid improvement in February was due to not re-injuring my feet for more than a month, and this in turn was due mainly to rest and custom orthotics, combined with the rest of what we learn here. I did re-injure them repeatedly in December and sometimes in January, because I was still learning and making too many mistakes.

Carole C

Re: Orthotics for feet

Joe S on 7/31/02 at 23:42 (091229)

wow. That's pricey. We charge 250 in and out the door and that includes a plaster cast.

Re: Orthotics for feet

Joe S on 8/04/02 at 22:18 (091586)

Footmax are not custom orthotics. They match your foot to an orthotic shell. They are customized for you but are not custom. The only way to get a rtue custom orthotic is to have a molded cast of your foot with an orthotic built around that cast. Adjustments can be made to the positive cast according to measurements taken during the hands on biomechanical exam.

Re: Orthotics for feet

john h on 8/05/02 at 13:36 (091644)

Dr.Joe: picky picky picky! I pay $400 for othotics and now you tell me they are not custom. Are they not custom in that only my feet could generate the exact computer impressions on that mat? No others feet will produce my excact computer generated impression. Well, anyway having had two sets that would qualify as custom I am more happy with these than my Sportsthotics (casted) and the other custom soft orthotic made from a foot impression in a box.

Re: Orthotics for feet

BG CPed on 8/05/02 at 18:34 (091672)

Well the Footmax are not custom. They should be called custom fit perhaps but they are not custom in the true sense. They use a statis mat and have you walk over it. This gives a crude topograph or cast like image. If a person has a hypermobile foot that overpronates then taking a 'snapshot' of the foot in that poor position is a bit flawed, much like taking an eye exam while you squint a bit.

Thjat info is sent to Canada where the techs will look at the colors e.g. elevations and shapes. Techs then pick out the closetst shell from a selection of pre-made shells. There is never an actual positive mold made and no milling is done either so they are modified pre mades.

I am not trying to flame here and if the devices work and they are made from an old frisbee and cost $600 then they are worth it, that said the wholesale and ultimately retail cost for them is expensive for what is actually done. You could fill a cookie pan with kitty litter, walk through it, fill it with plaster and have a similar result.

The points about giving refunds has two sides. Orthotic therapy can be very effective, it can also fail in some cases. Failures depend on many factors and PT compliance is one aspect. Skill level or lack thereof on the Practitioners part is also a factor. I give both verbal and writen instructions. I also measure the pt feet both arch and heel toe as well as go over proper footwear.

As much as I dislike the Gov I would welcome an orthotics certification board that would cover all practitioners. There are too many slimey types in the business as well as folks with good intentions just lacking the skills and tools to do a proper job.

I have had my share of failed orthotics but I have had many morepostive results. I dont think anybody gets a refund when your Stockbroker, Lawyer or Teacher does not 'fix' the problem or get 100% results. If you get a reaction from say Celebrex and break out in hives after 3 days, you dont return it to pharmacy for a refund. It was givin to hopefully relieve symptoms, as it does in many thousands. Unfortunatly it doesnt have a 100% success rate.

I only charge $175 a pair and do them in an hour. Because of insurance company nonsense I dont accept any insurance and only will bill for work comp or auto.

I used to charge $175 for auto thinking I was being nice and I would get taken care of since my competitors charge $350 plus. The last straw was from State Farm dragging out a claim that they originally approved and it took over 6 months to collect after tons of paperwork and calls. Now they all get charged what my competitors charge. Since I dont participate in medicare/medicaide I can do that. Many pt have no idea what extra crap you can be subject to when doing billing, just ask a medical biller I think they rank up with air traffic controllers.

Re: Orthotics for feet

Joe S on 8/08/02 at 20:27 (092021)

We charge 250 for orthotics made from a neutral position cast. At least yuo didn't pay 250 or whatever they cost for the alznners. Footmaxx does not make true custom functional orthotics. They take your measurements from their static gait mat that you walk across three times and from those three computer generated pressure analyses, they choose an appropriate shell for you. Customization can then be performed. I personally don't have a problem with footmax or their products. I've used them before. I also don't believe every single person with heel pain needs a custom orthotic. Many people can be effectively treated with an over the counter prefab. I do like the footmax orthotics for diabetics though. I like the fact that I can see where their weight is being distributed after an amputation. From that we can make an accommodative orthotic to help offload the high pressure areas.

Re: Orthotics for feet

Joe S on 8/08/02 at 20:30 (092022)

Very well stated.