the singing podiatrist.com

the foot stuff

custom foot orthotics

In British Columbia today custom foot orthotics are prescribed by a long list of professionals that includes podiatrists, medical doctors, physiotherapists, chiropractors, naturopaths, occupational therapists, massage therapists and pharmacists. Orthotics can also be obtained from shoe stores, orthotic stores, mall kiosks, the PNE and through the mail. The types of devices and expertise with which they are prescribed and fabricated varies widely. Most people who obtain custom foot orthoses trust that the prescriber and supplier of these devices conforms to some professional standard. Unfortunately this is not always the case. The dispensing and fabrication of foot orthotics has become a huge market outside the medical field - and there is no shortage of business people who have cashed in. The problem from my perspective as a podiatrist is that orthotics and the foot problems that create the need for them is not a "market" in the traditional business sense. Many people can benefit from wearing properly prescribed and fabricated custom orthotics. And there are many people who are sold "custom orthotics" that not only will not help them but could seriously hurt them.

First things first. It's crucial to have an accurate diagnosis of what the problem is. Podiatrists and sports medicine physicians are the most qualified health care practitioners to diagnose a foot problem that is causing lower extremity pain. A quick example to illustrate the point - an older woman goes to a shoe store that claims to make custom orthotics. She is suffering from exquisite foot pain and decides that for $350 it's worth a try. The salesperson convinces her that the orthotics are very effective and they would fit perfectly into her new $200 shoes. She buys the orthotics and though they're comfortable, they don't improve the foot pain at all. Some months later she sees her doctor and finds out that her foot pain is in fact caused by decreased blood flow due to diabetes. She sees a specialist who determines that she needs her diabetic medication increased and after several weeks the pain subsides.

Once you have a proper diagnosis, orthotics may be part of the treatment plan. They are usually not a cure-all. Often there are other treatments that need to be followed along with the orthotics - new shoes, massage, stretching, physiotherapy, activity modification are a few examples.

If orthotics are recommended what should you do to ensure that you will receive the best orthotic for your problem and your feet?

1. Don't be afraid of "rigid" or "hard" orthotics. It is true that a rigid device (if made incorrectly) can worsen your symptoms and be unbearably uncomfortable. The key to comfort in a hard orthotic is that it is made from a non-weightbearing cast of your foot. From that position, the practitioner can position the joints of the foot in the most stable position and hold it there while the cast hardens. The orthotic made from such a cast will hold your foot (for the most part) in the corrected position. Generally speaking, the more flexible the foot, the harder the material needs to be. Feet that are already tight and inflexible tend to need softer, shock-absorbing materials. If a hard orthotic is not comfortable, there are many possible reasons why. The practitioner can determine if it is incorrect casting, improper balancing of the orthotic, poor decision making regarding materials, improper break-in of the devices, or wrong foot wear. Some people simply cannot tolerate hard orthotics - often those with fibromyalgia, arthritis, soft tissue disorders or "sensitive" feet.

2. Be absolutely certain that you are being evaluated by someone who understands foot and lower extremity biomechanics and has experience prescribing orthotics and dealing with complications and problems related to wearing orthotics. You should be encouraged to return to the orthotic prescriber for follow-up. The initial assessment should consist of a thorough evaluation of your foot function, including gait analysis; analysis of foot wear, activity level and specific physical activities that will require the use of orthotics; determination of specific complicating factors such as painful callouses, leg length discrepancy, presence of arthritis, post-surgical deformities, etc.; and, evaluation of previous orthotics to determine reason for failure and improve the chances that the new devices will work better than the old ones.

Once you have your orthotics what should you do to enhance their effectiveness?

1. Break them in slowly. It's actually the feet and lower extremity that need to be broken in. The ideal is to start with one hour the first day and add an hour a day of standing or walking. If there is pain anywhere, slow down the break-in. Do not exercise in them (except for walking) in the first week. Your first exercise session with the orthotics should be less intense than usual. There is no rush. Big changes will be occuring throughout many of your major skeletal structures. Your orthotics are working to undo damage which may have taken years in the making.

2.Watch for positive and negative adjustment signs. Positive signs include temporary muscle soreness and reduction in symptoms. Negative signs include worsening of pain in any joint, arch discomfort in the devices, onset of callousing on pressure points, difficulty walking and the awareness that the orthotics don't feel comfortable. Watch for localized swelling and pain in the metatarsal area - orthotics have been known to cause stress fractures in extreme cases.

3. Be willing to wear the shoes that work best with orthotics. The shoes should hold the orthotic and foot in your shoe snugly. Usually a lace-up shoe with moderate to deep heel-seats work well. Avoid shoes with open heels, heels over 1 inch or those which cause your orthotics to rock over the arch area. Some shoes - such as sandals and slippers may completely negate the therapeutic value of your orthotics. Your orthotics should fit in the shoes easily without being wedged against the sides of the shoe. Generally speaking, the shoe insole comes out so the orthotic is functioning on a flat surface. You may need to add a flat cushioned insole to replace the cushioning if the shoe is no longer comfortable with just the orthotic.

4. Wear the orthotics as much of your standing and walking time as possible and for all exercise. Most people can get away with wearing dress shoes and sandals without the orthotics for short periods of time.

5. Return to the prescriber of the orthotics if there are problems. Minor modifications will often alleviate most problems. If you are not happy with your orthotics it is crucial that you return to the prescriber (the medical person who suggested them) and the provider (either your podiatrist or orthotic shop) to let them know. You have probably spent alot of money - and the consumers (users) of orthotics are the only ones who can raise the standard of care by ensuring that problems are reported.

Who should be careful wearing custom orthotics?

1. People who have any of the following conditions: very tight calf muscles; severe arthritis with fused joints; normal foot function; ankle or subtalar joint fusion; diabetes, especially with neuropathy; fibromyalgia.
2. People who only wear sandals and high heels.
3. People who cannot wear them consistently. It often does more harm to wear them inconsistently.

What does a custom orthotic do that a generic arch support does not do?

Basically, custom foot orthotics change the way the ground pushes up against the foot. It does so in such a way as to control (not stop entirely) foot joint pronation. Orthotics are usually used to decrease pronation but can also be used to enhance pronation (in a foot that is maximally pronated and needs extra pronation to occur for shock absorption). If the foot is not casted in a non-weightbearing position, the practitioner cannot adequately position the foot where it should ideally be positioned in order to control pronation. Because the foot is casted with precision, and the orthotic is hard - it is possible to change the way the foot functions. Generic arch supports simply provide cushion under the arch. They do not predictably alter the biomechanics (pronation) of the foot.

When do custom orthotics need to be replaced?

Sometimes they can be worn for 10 or 20 years. The hard materials should last indefinitely. The soft materials often need to be replaced yearly. If your orthotics are controlling your symptoms and fitting in your shoes then they do not need to be replaced. If you have a recurrence of your original symptoms or onset of new symptoms while wearing orthotics - you need to be assessed. Modifications to existing orthotics should usually be tried first before starting from scratch. Feet do change over time and this may cause discomfort and lead to the need for new orthotics. People with progressive arthritis and old injuries usually need orthotics replaced every two to three years.

Summary

Many people swear by their orthotics - they are miraculous in some cases. Other people have sworn off orthotics because they have experienced nothing but problems. As with any medical problem, you must seek out the professional who will give you the best possible advice. If you try to take short-cuts you may be unhappy with the results. It can be difficult because there are so many options and so many people recommending, prescribing and dispensing custom orthotics. Custom foot orthotics are a medical treatment option for a number of foot and lower extremity symptoms. Obtain medical advice to the best of your ability and follow your instincts.