Orthopedists, pedorthists collaborate to treat foot problems

New materials plus a raft of specialists and suppliers complicate the custom vs. over-the-counter decision. Learn how to sort it all out.

Part II: Leaders pinpoint the best ways to meet footwear challenges

Moderator: Carol C. Frey, MD Associate Professor of Orthopedic Surgery, University of California Manhattan Beach, Calif.; Foot and Ankle Section Editor, Orthopedics Today Panelists: Dennis Janisse, CPed President and CEO of National Pedorthic Services Inc.; Clinical Assistant Professor, Dept. of Physical Medicine and Rehabilitation, Medical College of Wisconsin Michael S. Pinzur, MD Professor, Adult Orthopedics & Rehabilitation Foot and Ankle Surgery Loyola University Medical Center, Maywood, Ill. Jeffrey E. Johnson, MD Associate Professor, Orthopedic Surgery, Orthopedic Surgery Center, Center for Advanced Medicine, Shriners Hospital for Children, The Sports and Orthopaedic Center St. Louis, Mo. Pierce E. Scranton Jr., MD Orthopedics International Ltd., Seattle David Levine, DPM, C.Ped ACFAS Member, Pedorthic Foot Association member Frederick, Md.

Carol C. Frey, MD: There are 1500 certified pedorthists in the world today. They specialize in the design, fit, manufacture and modification of footwear, including foot orthoses. When would a patient be referred to a certified pedorthist? What is different about this specialty as compared to an orthopedic foot and ankle specialist or a podiatrist?

Dennis Janisse, CPed: Actually there are closer to 2000 CPeds — with 1500 being in the United States. The CPed does not diagnose or prescribe; as a result the patient is referred by a MD or DPM to a CPed when conservative foot care is needed. A CPed certainly understands the diagnosis and can recommend or assist in determining what pedorthic modalities or services are needed, but only with the appropriate diagnosis from the physician.

Jeffrey E. Johnson, MD: Today, patients are able to obtain a “foot orthotic” from many non-traditional sources, including chiropractors, physical therapists, sporting goods stores, shoe repair shops, in addition to myriad mail order or online sources. By referring a patient to a certified pedorthist or orthotist with pedorthic training, I think there is a better chance that the patients will have an orthosis fabricated that will fit their individual needs.

David Levine, DPM, CPed: It depends on the level of training of the CPed. In my practice, I employ two CPeds. A CPed, by definition, fills prescriptions. If the prescription can be filled in such a way that the physician, CPed, and patient are all in alignment, then a CPed is perfectly qualified. If the physician does not feel comfortable writing the Rx or doesn’t understand what exactly the patient needs, then a prescribing physician such as a podiatrist or orthopedist would be necessary.

A CPed fills the RX written by a physician. The CPed functions as an extension of the physician carrying out the orders written. A podiatrist can diagnose, prescribe and in some cases fabricate the devices. For instance, in my practice I have my own orthotic lab as well as CPeds to help fill the Rxs that I write.

Michael S. Pinzur, MD: This is best answered by a certified pedorthist. My experience would suggest that the certified pedorthist tends to be more experienced and knowledgeable at advising and fabricating specific foot orthoses and shoe modifications than a certified orthotist. The CPed tends to be more knowledgeable and comfortable with the new flexible materials, as opposed to the CO, who tends to be more comfortable with heat-moldable plastics.

Pierce E. Scranton Jr., MD: A certified pedorthist has special understanding both of the physical properties of shoes as well as how to link those properties to the special force distribution needs of an orthosis. They add an additional therapeutic dimension to distribution of forces under an individual with abnormal gait and symptomatic feet.

Frey: Can most patients avoid a custom-made orthosis by simply having their shoes custom fit or modified? What percentage of patients that you see in your practice actually requires a custom foot orthosis?

Janisse: This depends so much on the problem or diagnosis. Often, hindfoot instability, hyper pronation, or supination can be controlled with appropriate footwear. Certain shoe modifications can certainly relieve pressure on plantar prominences, but if there is no fatty tissue, an orthosis of some sort is probably necessary by the time a patient is referred to me.

Johnson: Over the past five to 10 years there has been a significant improvement in what is considered an “over-the-counter” or pre-made foot orthosis. The same high quality materials can now be found in many pre-made orthoses. Therefore, many conditions that require a foot orthosis are able to be treated with a pre-made orthosis as long as the foot does not have a significant deformity or an unusually cavus or planus foot shape. Approximately 60% of the problems I see can be managed with a pre-made orthosis that has been modified for treatment of metatarsalgia, hallux rigidus, plantar fasciitis, and the insensate foot without deformity. Conditions that require placement of laminated materials in the orthosis to make it stiffer or areas cut out that are replaced with a viscoelastic polymer will need a custom orthosis. Also foot deformities that require a significant amount of posting such as in severe pes cavus or pes planus would need a custom orthosis.

Levine: Shoes and orthotic devices function differently and have different purposes. The best a shoe can do is offer support around the foot. Although there may be some shoe modifications that can control frontal plane motion (such as a Thomas Heel), none will control the frontal plane motion as well as a custom orthotic device.

I would estimate somewhere between 10% to 15% of the patients that see me need custom devices. However, being in practice for several years has allowed me to establish a reputation for making orthotic devices and attract that type of patient.

Pinzur: There are a variety of pre-fabricated, commercially available insoles, foot orthoses, and cushioning devices available to the consumer. I generally advise most patients on which devices are available for trial. Before prescribing a custom foot orthosis, I frequently have the patient try an inexpensive pre-fabricated commercial device. We then make the decision whether there would be incremental benefit from a custom orthosis. This approach can even be applied to the diabetic population. Low-risk diabetics can often be managed with commercially available oxford tie shoes and non-custom accommodative insoles. Custom foot orthoses and depth-inlay shoes only become necessary when the patient has deformity that needs to be accommodated, and the patient has achieved a moderate, or high-risk status.

“Approximately 50% of the problems I see can be managed with a pre-made orthosis.” —Jeffrey E. Johnson

Scranton: Most patients do not require custom shoes or custom orthotics. Simple off-the-shelf heel pads, gel pads, metatarsal pads or accommodative orthotics are all that is necessary. My own practice is a tertiary referral practice and greater than 50% of the referred patients will require some specialized footwear or orthotic management.

Frey: What is the most common diagnosis that you see in patients that requires a custom foot orthosis?

Janisse: In my practice, the most common diagnosis is diabetes. I have a very specialized referral pattern, and the person living with diabetes is often one of the highest-risk and challenging patients. Other facilities have very high numbers of chronic plantar fasciitis, post-tib tendonitis, and certainly arthritis.

Johnson: The most common diagnosis in my practice that requires a custom foot orthosis is a coronal plane malalignment problem such as severe pes cavus or pes planovalgus. The second most common would be patients with diabetes mellitus who have some type of deformity or require significant offloading in an area of previous ulceration.

Levine: There are two different kinds of orthotic devices – accommodative and functional. Accommodative orthotic devices are primarly used to accommodate deformities or locations of pressure. The lead example of this is DM. As far as functional orthotic devices, plantar fasciitis is certainly one of the top diagnoses. But there are several types of musculoskeletal imbalances that benefit from orthoses such as various types of tendonitis and even hallux limitus.

Pinzur: Diabetes mellitus.

Scranton: Excessive pronation of the foot.

Frey: There are many ways to fabricate a foot orthosis, including the following: casting, step-in molds, computer-assisted devices, foot pressure graph pad and force plates. What method do you most commonly use and why?

Janisse: All the different casting techniques work. The secret is to be comfortable and accomplished at the technique you choose. There obviously can be a lot of debate. I tend to use a lot of foam box impressions. It is quick, clean, and in the right hands, quite accurate. It is also easy to transport and modify.

Johnson: When a true custom total contact insert is required, the pedorthist used by my practice employs a foam-box impression technique or occasionally a plaster slipper mold technique to create a positive model over which the orthotic materials will be conformed. This allows the pedorthist to hold the foot in the position that is desired rather than many of the other techniques that do not give the fabricator as much control over the position of the foot when the measurements are taken. In addition, with this method, the posting is usually added extrinsically. This allows these modifications to be easily moved or customized to adjust the orthosis for the patient once they begin wearing it. Many of the other techniques mentioned will incorporate the metatarsal pad where it is felt to be needed (intrinsic posting) and is much more difficult to change later once the orthosis has been fabricated.

Levine: I don’t believe that there is one right way to cast, but I do think that the key for each practitioner is consistency from patient to patient. I also think it is important to have criteria established for when certain casting techniques are utilized. For instance, with functional devices, I use plaster and for accommodative devices I use either sheet wax or plaster and even foam.

Scranton: Step-in molds.

Frey: Many insurance companies now require a foot and ankle biomechanical examination to be performed and recorded before they will authorize payment for foot orthoses. What constitutes a good examination?

Janisse: Fortunately, we have not found this to be true, and National Pedorthic Services is practicing in four states. I have a number of payers that actually require specific deformities or conditions for reimbursement. For example, a bunion is not reimbursable, but hallus valgus of certain degrees often will qualify for foot orthoses and/or shoes. Arthritis is not adequate, but add a deformity, and it is.

“The more hard plastic foot orthoses, although easier to fit into dress footwearm seem to look very similar from patient to patient regardless of diagnosis.” —Jeffrey E. Johnson

Johnson: The foot and ankle biomechanical examination is one of the primary areas of focus in pedorthic education leading to certification and also in all of their continuing medical education programs. A thorough biomechanical exam would include a standing inspection and gait analysis both with and without footwear to assess alignment, gait, stability and muscle coordination. Standing inspection will demonstrate significant coronal, sagittal or transverse plane malalignment. In the seated position, examination will allow for general muscle strength testing, joint flexibility and to determine how much of a deformity could be passively corrected with an orthosis. In addition, a screening for significant vascular disease or peripheral neuropathy is an excellent role for a pedorthist caring for patients with diabetes. An appropriate referral to a specialist after one of these screening exams can be limb saving for these patients. A visual assessment and palpation of the plantar aspect of the foot will demonstrate areas of high pressure or pain that will require off loading with the orthosis.

Levine: A biomechanical examination includes a complete history and physical with attention to the lower extremities. You should ask patients about their activity level, occupation and shoes most commonly worn. Joint range of motion should be inspected from the hip down to the first MTP joint. In addition, leg-length discrepancies should be looked for as well. Initially, gross inspection is necessary in order to check for overall joint position and symmetry. Relationships of joints to each other is then assessed. For instance genu valgum and varum are important in order to determine how the orthotic will be posted. A good biomechanical exam is one that assesses the lower extremities and notes overall position, relationships and asymmetry.

Scranton: Video taped gait analysis, physical examination of the foot and ankle documenting motion, stability, hindfoot, arch, forefoot anatomy and biomechanics, and at least a Harris Mat force analysis.

Frey: Is there a different philosophy about the use and fabrication of orthosis among orthopedists, podiatrists and certified pedorthists? What differences do you see? Does one group prefer a more rigid device, for example?

Janisse: In the big picture, certain groups work with larger populations of patients that have more normal feet with biomechanical deformities and are not willing to and don’t necessarily have to change their footwear. This group of patients can often benefit from less bulky, more rigid devices. Other groups with a more chronic type diagnosis and more significant foot deformities benefit from more complex foot orthoses that incorporate control and function as well as shock absorption and cushioning, and require footwear with more depth. I sincerely believe the end result can be accomplished with both types, rigid and semi-rigid.

Johnson: There appears to be a significant difference in philosophy about the use and fabrication of orthoses, especially between orthopedic surgeons and podiatrists.

A certified pedorthist is obligated to fill the prescription that is written by a referring physician. Therefore, it is difficult sometimes to know whether a foot orthosis fabricated by a certified pedorthist is actually what they would have recommended in this situation or whether they are filling a prescription at the specific request of a practitioner.

I see orthopedic surgeons generally prescribing foot orthoses fabricated of heat-moldable closed-cell polyethylene foam materials of which there are many different densities, and the base of the orthosis is typically posted with cork or Pelite. I also noticed that almost 100% of the foot orthoses prescribed by podiatrists are a hard acrylic, plastic or carbon fiber material with a small varus or valgus wedge built into the heel. The covering layer is typically a firm vinyl, and usually there is very little metatarsal padding. If a metatarsal pad is utilized, it is usually posted intrinsically within the layers of the covering material and is often much more proximal than the metatarsal heads.

For mild pes planus, I understand the rational for the more rigid orthosis that I have observed prescribed by the podiatric community; however, I do not quite understand the rationale for utilizing this very same type of foot orthoses for patients with metatarsalgia, or any other condition in which additional shock absorption as well as some moderate support would be helpful.

In my observation, the more hard plastic foot orthoses, although easier to fit into dress footwear, seem to look very similar from patient to patient regardless of the diagnosis for which it was prescribed. The softer, cork-posted multi-laminate-type foot orthosis is more bulky but is able to be customized more easily for a specific problem or painful area.

Levine: Yes. CPeds seem to focus primarily on accommodative devices unless they are closely aligned with a podiatrist. It takes more time and understanding to learn how to fabricate a functional device.

Accommodative devices, by their nature, are typically softer devices than functional devices. In the 1970s, when orthotic devices achieved greater recognition, rigid devices were in vogue. Over time podiatrists have drifted away from the rigid devices, in general. The semirigid devices are now the most popular.

There are a variety of materials from which to select and there is not just one right way to do things. I think that is why there are so many different types of specialists involved in the fabrication of orthotic devices.

Another factor is the patient. If you take a 95-pound female with a high arch and fabricate a device from a thin polypropylene it may actually function as a rigid device as compared to a low arched 180-pound male. The shape of the orthotic cannot be overlooked in the design. In other words, because of the contour, a device with a high arch is a lot less flexible than one with a low arch.

Pinzur: It has been my experience that podiatrists are more likely to use rigid or semi-rigid orthoses, while orthopedic foot & ankle surgeons are more likely to prescribe custom flexible or semi-rigid orthoses.

Scranton: This may vary from region to region. Where I practice, podiatric orthoses tend to be rigid plastic, and certified pedorthotists’ orthoses tend be firm but accommodative.

Frey: There have been some excellent studies that indicate that an over-the-counter device, such as a cushioned heel insert, may perform better in the treatment of plantar fasciitis than a custom-made foot orthosis. What are your thoughts about over-the-counter devices, not only for plantar fasciitis, but other diagnoses as well?

“The person living with diabetes is often one of the highest-risk and challenging patients.” —Dennis Janisse

Janisse: It is my impression that over-the-counter devices work well for newly diagnosed plantar fasciitis. In chronic cases of plantar fasciitis, a custom foot orthosis has also been shown to be an effective treatment. I feel there are definitely indications for both off-the-shelf and custom devices to treat the same condition in varying degrees of severities. Examples can even include diabetes, pronation and post-tib tendonitis.

Johnson: I agree with the conclusions of these studies on plantar fasciitis and typically order a custom foot orthosis only when there is deformity that cannot be accommodated by a pre-made orthosis. A pre-made can also be modified with cutout areas filled with foam or gel for high-pressure painful areas. Many patients have commented that they thought that a well-made pair of athletic shoes was superior to any foot orthosis that they had obtained for heel pain.

Levine: When a patient presents with plantar fasciitis it always makes sense to start simple and work your way up to more complex treatments. Starting out with an off-the-shelf device at the first visit makes more sense. I believe in arch support more than heel cushioning as a way to relieve plantar fasciitis. More can be achieved with an arch support. Not only can you raise the heel, but additional support for the plantar fascia will help as well. Since no two feet are alike, I also recommend to the patient to try different devices on before purchasing. In my shoe store, which is an extension of my practice, we have the luxury of offering this service to both patients and customers. In addition, we have heat-molded devices as well. It never hurts to start simple. If the OTC devices fail in providing relief, then custom devices are sometimes necessary.

Scranton: Over-the-counter devices are almost always my first choice unless there is a specialized need or asymmetric gait.