Best orthotics fitting procedure?

[HenryH]

I know that podiatrists commonly use a plaster casting process to mold new orthotics for patients. However, I recently heard of an alternative procedure that involves walking across some sort of floor mat that sends signals and images to a computer.

Just out of curiosity, is one orthotics fitting procedure better than the other?

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[Dr_Feelgood]

I know that podiatrists commonly use a plaster casting process to mold new orthotics for patients. However, I recently heard of an alternative procedure that involves walking across some sort of floor mat that sends signals and images to a computer.

Just out of curiosity, is one orthotics fitting procedure better than the other?

Over the counter

 

[Feli]

You will learn all of this in biomechanics and lab; it really depends what kind of orthotics you are talking about.

The computerized mat is nice and saves time for accomodative orthotics (soft insterts for padding/cushioning). It can show high pressure areas well.

For functional orthoses (rigid orthotics for correction or support), you want to stick with plaster casting. The step-in foam or computerized mat imprints are convenient, but they just don't fully capture the forefoot to rearfoot relationship that you need for correction.

 

[SportPOD]

You will learn all of this in biomechanics and lab; it really depends what kind of orthotics you are talking about.

The computerized mat is nice and saves time for accomodative orthotics (soft insterts for padding/cushioning). It can show high pressure areas well.

For functional orthoses (rigid orthotics for correction or support), you want to stick with plaster casting. The step-in foam or computerized mat imprints are convenient, but they just don't fully capture the forefoot to rearfoot relationship that you need for correction.

And as it always is stated, once the foot hits the ground, everything changes.

 

[HenryH]

For functional orthotics that would be worn during exercise, wouldn't the ones made on the computerized mat work better? I assume this because of the fact that, as stated by Feli, the electronic mat can detect high pressure areas, which seems like a benefit when considering that orthotics will be walked/run in while being worn. In other words, is the plaster cast of someone's foot in a stationary position really going to create orthotics that would give proper support when running, walking, etc. (e.g., doing things other than just standing)?

 

[Feli]

For functional orthotics that would be worn during exercise, wouldn't the ones made on the computerized mat work better? I assume this because of the fact that, as stated by Feli, the electronic mat can detect high pressure areas, which seems like a benefit when considering that orthotics will be walked/run in while being worn. In other words, is the plaster cast of someone's foot in a stationary position really going to create orthotics that would give proper support when running, walking, etc. (e.g., doing things other than just standing)?

The answer to this could probably go 10 pages long and would be way over your head as a pre-pod. If you go to pod school, you will take biomechanics, make some orthotics, read some literature, and eventually form your own opinions from experience as a practitioner.

This is question is not something simple, such as film versus digital X-rays. Responses and preferences might vary, but most of the best pods still I've met still use plain old plaster casting, by choice, for functional orthoses due to the rearfoot relationship I mentioned. You'll find guys with modern offices that have digital XR, plasma TVs in the waiting room, etc.... but they still use plaster casting for functional orthotics. There is really no way to know what the foot's neutral position is if you're using a mat. That is fine for accomodative, but it usually doesn't cut it for producing a good functional orthotic.

This might help you; it explains things a bit in layman's terms:
http://www.footankle.com/custom-orthotic-casting.htm

 

[Stafocker]

For functional orthotics that would be worn during exercise, wouldn't the ones made on the computerized mat work better? I assume this because of the fact that, as stated by Feli, the electronic mat can detect high pressure areas, which seems like a benefit when considering that orthotics will be walked/run in while being worn. In other words, is the plaster cast of someone's foot in a stationary position really going to create orthotics that would give proper support when running, walking, etc. (e.g., doing things other than just standing)?

Well, not really. If you think about it, high pressure areas don't always translate into a 3-D image. A mat will only give a 2-D image and will tell you where the pressure areas are that might need to be off-loaded. This is probably better for ppl with Metatarsalgia, etc. I think the CLEAR group has an article out from APMA conference talking about high pressure areas in diabetes, but that it doesn't corrolate to a 3-D image or device for support, rather a warning spot to off-load.

Just image looking at a 2-D mat image from the computer, you have NO idea how high someone's arch or low someone's arch is, all you see is a blank area, so you have to guess....

A custom is just that, custom to ppl's feet and will give a better impression, though may not cushion the high pressure areas. But i guess it most likely depends on "why" you are making these devices. The "new" computerized (some use a laser sensory box) techniques have been around for a while and maybe more for flash/dance than substance.

A recent article in the Arch of Intern Med 2006 by Landrof et al found that foot orthoses do produce "short-term" benefits in reduction of pain for people with PF, but not "long-term". There was no difference between custom devices and prefab (over the counter) orthoses, but a significant difference in pain reduction was found compared to using the soft foam (sham) orthoses with the other two. hope this helps

 

[HenryH]

A recent article in the Arch of Intern Med 2006 by Landrof et al found that foot orthoses do produce "short-term" benefits in reduction of pain for people with PF, but not "long-term".

Hold on a second -- I was under the impression that orthotics were one of the staple treatments of podiatry for various foot disorders/conditions (such as high arches)...however, according to this study, they present no evidence of providing long-term benefits...?

There was no difference between custom devices and prefab (over the counter) orthoses, but a significant difference in pain reduction was found compared to using the soft foam (sham) orthoses with the other two. hope this helps

So, in other words, custom, molded orthotics (according to studies) have no treatment advantage over generic, store-bought orthotics? If there is hardly any evidence backing up the benefits provided by orthotics, then why do podiatrists prescribe them so often?

 

[Feli]

... If there is hardly any evidence backing up the benefits provided by orthotics, then why do podiatrists prescribe them so often?

Like most topics in modern medicine, there is literature on both sides of the issue. Hopefully the body of literature will continue to grow with large scale quality studies to the point where meta-analysis can be performed.

For orthotics, it's a fairly mixed bag in studies, and the results of a functional orthotic device depend a lot on how good the casts and choice of materials is (which is why the mats or foam are pretty suspect). Overall, there is almost certainly more research supporting orthotics than not. Most DPMs I've been in clinic with will start the patient off with an OTC orthotic in hopes of saving them money, and they can then progress to a more expensive custom device if the patient isn't getting good enough results. Some people get satisfactory results from just the OTC inserts, some progress to custom orthotics and get good results there, and others have to keep trying other treatments.

In the end, the proof is in the results; the attendings who have helped hundreds of patients know a lot more than students and residents who have mostly just read a few articles or casted patients but never seen them at follow-up. There are some podiatrists here in Miami who offer a full refund to patients if they are not satisfied with their custom orthotics, and they barely have any returned (usually in patients with feet so flat that surgery or other advanced treatments are really their only viable options). When you see patient after patient willing to spend $400 out of pocket for new orthotics due to the benefit they got from their last pair over the previous few years, I'd say they certainly work for some people .

You certainly don't have to use every treatment you learn in school, but you want to know what's out there and available. Ultimately, like I said, you will use a combo of the literature, accepted standards of care, and, mainly, your clinical judgement/experience to decide what's best each individual case. If you went to 10 different pods for painful flatfoot, they'd all at least mention orthotics as a treatment option.

 

[Stafocker]

Like most topics in modern medicine, there is literature on both sides of the issue. Hopefully the body of literature will continue to grow with large scale quality studies to the point where meta-analysis can be performed.

For orthotics, it's a fairly mixed bag in studies, and the results of a functional orthotic device depend a lot on how good the casts and choice of materials is (which is why the mats or foam are pretty suspect). Overall, there is almost certainly more research supporting orthotics than not. Most DPMs I've been in clinic with will start the patient off with an OTC orthotic in hopes of saving them money, and they can then progress to a more expensive custom device if the patient isn't getting good enough results. Some people get satisfactory results from just the OTC inserts, some progress to custom orthotics and get good results there, and others have to keep trying other treatments.

In the end, the proof is in the results; the attendings who have helped hundreds of patients know a lot more than students and residents who have mostly just read a few articles or casted patients but never seen them at follow-up. There are some podiatrists here in Miami who offer a full refund to patients if they are not satisfied with their custom orthotics, and they barely have any returned (usually in patients with feet so flat that surgery or other advanced treatments are really their only viable options). When you see patient after patient willing to spend $400 out of pocket for new orthotics due to the benefit they got from their last pair over the previous few years, I'd say they certainly work for some people .

You certainly don't have to use every treatment you learn in school, but you want to know what's out there and available. Ultimately, like I said, you will use a combo of the literature, accepted standards of care, and, mainly, your clinical judgement/experience to decide what's best each individual case. If you went to 10 different pods for painful flatfoot, they'd all at least mention orthotics as a treatment option.

well said