What are orthoses?
Orthotic devices, or
Orthoses, are inserts for the shoes (like the ones to the right made by
Langer Orthotic Laboratory), which are made to control various types of abnormalities
of the lower extremity (foot, ankle, leg, knee and hip).
has shown that back problems, shoulder and neck complaints and
scoliosis of the spine can often be traced to abnormal
foot function. Thus it's important for your podiatrist
to evaluate the lower extremity as a whole to provide for appropriate orthotic
control for foot problems.
sometimes confused with simple arch supports, (in fact, simple arch supports
are often misrepresented as orthotics by retailers), but they can do far more than
simply support the arch. They help make standing, walking and running
more comfortable and efficient by altering the angles at which the foot
strikes and functions across a walking surface, by controlling and
redistributing weight when it is transferred incorrectly as part of
some sort of functional abnormality.
Research has shown that back problems frequently can
be traced to a foot imbalance. It is just as likely that foot problems are
brought about by a back imbalance. It's important for your podiatrist to
evaluate the lower extremity as a whole to provide for appropriate orthotic
control for foot problems.
||Because orthoses are
used for many types of abnormalities, there are many types of devices, made
from many types of materials. The common denominator, however, is
that all are concerned with improving foot function and minimizing stress
forces that could ultimately cause deformity and pain.
How are Orthotics different from Orthoses?
It's a grammar
thing. "Orthoses" is the noun; "orthotic" is the
adjective. So, it's proper to say that a patient may need
orthoses. And it's proper to say that a patient may need orthotic
appliances. But it's technically improper to say a patient needs orthotics.
people--even doctors--seem to use the word "orthotics" in
exactly this way, even though it's incorrect
Who makes orthoses?
As foot specialists
trained both in the diagnosis and medical care of the foot and
in the mechanical function of the body (biomechanics), Doctors of
Podiatric Medicine, (D.P.M.'s or Podiatrists), are the practitioners
best trained to examine, order appropriate tests and diagnose abnormal
foot and leg dysfunction and to design and prescribe the proper appliance to
address that abnormality. Indeed, biomechanical assessment and
treatment is such an integral part of podiatric medicine, that it
is even a field of specialization within the profession. In fact, this
is one of
(Dr. Schumacher is board
certified by the American Board of Podiatric Orthopedics and Primary
Podiatric Medicine (ABPOPPM) and is a Fellow in the American College
of Foot and Ankle Orthopedics and Medicine.)
There are also
individuals in other medical and para-medical fields, too, who make
various foot inserts. As you might suspect, the quality of these devices is
variable. The problem with individuals in these fields
offering foot advice and care is that many have little in the way of
formal training in lower extremity anatomy, and even less training in
biomechanics (the study of how the body functions).
In fact, it is
an unfortunate fact that in
British Columbia (as in many jurisdictions), there is currently no minimal standard of training required
to make orthoses. Thus, you can always find someone wearing a white
coat, but with literally nothing in the way of formal training in any
medical or biomechanical field, diagnosing your abnormality and
attempting to correct it as he or she sees fit.
Often these individuals are
simply sales people made up to seem like they're trained in some way.
Such salesmen will
often work trade fairs at the booth right next to the slicer-dicer kitchen
gadget salesman, at kiosks in the mall, at shoe stores, ski boot stores,
independent orthotic stores, on TV--they even
go door-to-door. We
had one patient who bought an "orthotic" from one such individual,
and when she went into a store to buy a stereo two weeks later, she
encountered the same salesman there.
in British Columbia has individuals dispense
$12 over-the-counter devices, yet actually charge as much--or even more--than true, custom-made
because many individuals making these devices
may have no training and no credentials, any extended medical benefit
program you may have is likely to be unwilling to reimburse you for these lesser
The money issue is bad
enough, but the wrong type of device may not really address what's wrong--and
it may make symptoms worse, even creating new problems.
So if you're
considering an orthosis, this field is definitely "buyer
beware". As the level of
training of many selling orthotic appliances is frequently minimal, the
approaches used by non-podiatrists are often, not-surprisingly, quite
different in philosophy and in practice from that of podiatrists.
How are orthoses made?
First, a careful
history should be taken to rule out a general medical cause or
relation to the patient's problem.
Next, the patient
undergoes a thorough physical examination. Radiographs or other imaging
studies may help to assess any underlying structural abnormalities.
assessment and a Gait analysis, (a study of how one walks).................
then usually performed. The Achilles Foot Health Centre has a
state-of-the-art treadmill for just this purpose.
If and when we decide that orthoses
would be helpful, a non-weight bearing, (or in some cases, a partial
weight-bearing), plaster-cast impression is
taken, with the foot held in the desired, corrected position.
There are other ways to take an
impression of the foot, but these methods all have drawbacks. Standing
on ink-blot paper and taking a simple tracing
of the foot only show the foot in two dimensions, and even then, the foot
is in the abnormal, uncorrected position. Foam
box techniques and vacuum casting techniques
have the advantage of demonstrating a three-dimensional impression, and
the image may be taken quite quickly and without much mess (useful with young
children), but it may be difficult to hold the foot in the desired, corrected position with
this method. The impression is often made with the foot in whatever
position it happened to be in at the time, and so while the orthotic may
"fit" the foot, it may not really correct the actual problem
in any fashion whatsoever.
program imaging techniques attempt to image the
foot in gait, and this can be informative (if interpreted by someone who
understands biomechanics). But there are some potential problems
with using this technique to image the foot for an orthosis.
1. First, the image shows only one single
step, which may not be representative of the average step in gait.
2. Second, as they require the patient to walk across a flat plate in order to
create the image, these systems have the disadvantage of attempting to image
a 3-dimensional structure (the foot) in 2 dimensions.
3. Third, as the
computer makes its assessment only from the 2-dimensional image plate, the
computer can only "see" the bottom of the foot. The computer
has little in the way of ability to properly assess the structure or function
of other parts of the body in gait, such as the lower leg, the knees, the
femur, the hip, the back and so forth.
4. Fourth, these systems image the
foot when it is going through some sort of abnormal gait cycle. Indeed,
it must be abnormal or the patient wouldn't likely be getting orthoses in the
first place. The problem is that imaging the foot in an abnormal
position means that no assessment is made by the computer to assess the best,
corrected position in which the foot may be placed, nor is there an accurate
assessment of whether there are correctible positional abnormalities or
correctible limitations in range of motion in various joint. Thus, the
patient tends to get an orthosis that often holds the foot in the abnormal
5. Fifth, major decisions about what's wrong with the foot and
what is needed to correct it are often off-loaded by the computer to an
individual in a laboratory, sometimes thousands of miles away. Not only
do we not know what kind of medical or biomechanical training this
individual has, but he or she has never
even seen the patient. This situation is clearly inferior to having
someone who specializes in the field actually examine, diagnose and design the
Thus, we believe that in most
cases, the best
technique is to perform a good physical exam, including imaging studies (X-ray,
CT scan, etc.) as necessary, to assess structural problems, (which only a
podiatric physician or medical doctor can order), to perform a good
biomechanical analysis to assess the biomechanical abnormality, (which only a
podiatrist or someone with thorough training in understanding biomechanics can
adequately perform), and finally, in most cases, to use the plaster impression
method to capture a 3-dimensional impression of the foot, while in the
corrected position (which, again, requires a podiatrist or someone with a
great deal of biomechanical and diagnostic expertise to understand where the
desired position is for each, individual case).
Because of the amount of training and
knowledge required to diagnose and assess the patient, then design and
fabricate a device to correct the abnormality, it should be clear why
podiatrists, with more training in this arena than any other profession, are best-suited to perform this task.
Dr. Schumacher uses multiple
specialty orthotic labs from around the Canada, the United States, and even
other countries to make
certain the best device possible is made for each patient, to address his
or her individual needs.
kind of orthoses are there?
There are many types of
devices--a lot more than you'd think. There are devices for virtually
every activity and for virtually any pair of shoes. A good, professional
lab may make a dozen types of devices, an we may use a dozen different
But generally, there are several
families of devices about which we may make some generalizations.
designed primarily to control various types of abnormal function. Foot
and leg fatigue, muscle aches, connective tissue strains, knee, hip
and back pains may all be due to abnormal function of the foot, or a
slight difference in the length of the legs. In such cases, orthoses may
improve or eliminate these symptoms, which may seem only remotely connected to
are made out of various types
of plastics, graphites, and other similar materials. They
are custom-made from a mould of each individual foot,
with the foot held in the desired weight-bearing position. They
typically take up little in the way of extra width or length in the shoe,
they can take up some additional depth in the shoe, so proper
choice in materials for the style of shoe worn is
vital. Most rigid devices are guaranteed for life against
breakage, so unless the foot changes over time, they are long-lasting.
Basic Rigid Orthoses
Example of Soft Orthoses
Orthoses, on the other hand, are primarily designed to absorb
shock, increase balance, and take pressure off uncomfortable or sore
spots. It is usually constructed of soft, compressible materials, and
may be moulded by the action of the foot in walking or fashioned over a
plaster impression of the foot. It usually extends from the heel
past the ball of the foot to include the toes.
The advantage of any soft orthotic
device is that it may be easily adjusted to changing weight-bearing forces. The
disadvantage is that it must be periodically replaced. It is particularly
effective for arthritic and grossly deformed feet where there is a loss of
protective fatty tissue on the side of the foot. It is also widely used in the
care of the diabetic foot. Because it is compressible, the soft orthosis is
usually bulkier and may well require extra room in shoes.
designed to provide dynamic balance of the foot while walking or
participating in sports. This device is created appropriately for
the demands of each unique sport, and each unique athlete in mind. This
functional, dynamic orthosis helps guide the foot through proper
functions, allowing the muscles and tendons to perform more efficiently.
Inverted Orthoses are
devices that are designed to better control certain important joints in the foot
to give the patient even more control when required. They help reposition
the heel and ankle bone into a more "locked" position, thereby
stabilizing the bones and joints in the midfoot. This better maintains the
arch. These devices are
particularly useful in patients with posterior tibial dysfunction or very
flexible, collapsing feet when other devices simply don't work well.
Orthoses for Children are
effective in the treatment of many types of foot deformities and
biomechanical abnormalities, such as: severe pronation (flattening of the foot),
intoeing, outtoeing, splay foot (foot spreading out too much), metatarsus
adductus, crooked heels in stance, apophysitis (growth plate pain) and
midfoot pain from an accessory navicular (an improperly developed bone in the
There are many types of orthoses
for children, including well-known devices such as Schaeffer plates,
Whitman-Roberts plates and an entire family of different types of Gait plates.
Most podiatrists recommend that
children with such deformities be placed in orthoses soon after they start
walking, to stabilize the foot. The devices can be placed directly into a
standard shoe, or an athletic shoe.
Usually, the orthoses need to be replaced when the
child's foot has grown two sizes. Different types of orthoses may be needed as
the child's foot develops, and changes shape.
The length of time a child needs orthoses varies
considerably, depending on the seriousness of the deformity and how soon
treatment is initiated.
Now it is obviously easier to fit an orthotic appliance
like the ones above into some styles of shoes.........
than it is to fit these devices into
other styles of shoes................
So various thin devices.....
.....and other less-obtrusive devices.....
have been designed to fit non-standard foot wear.
Other specialized devices can be made for ski boots, snow boards,
ice skates, roller skates boot. Combinations of semi-flexible material and soft
material to accommodate painful areas are utilized for specific problems.
How long do orthoses last?
It varies greatly. Soft
orthoses tend to break down sooner than harder orthoses, and they may need to be
refurbished (though not replaced) regularly. An average individual may
need to do this yearly, though some may go several years and others may go
several months. It depends upon one's activity level, how much he
perspires, whether he works in water, and so forth.
Harder orthoses typically last
years and years. In fact, many types are guaranteed for a lifetime.
Earlier this year we had a woman come in for a check-up, and she had been using her orthotics for 27 years. At the time of that examination, the devices still
fit well, were still working well, and she may go many more years without
On the other hand, patients with
progressive conditions, like certain neurological or rheumatological problems,
for example, may require frequent updates to
their devices--not because they're wearing out, but because the foot is
continually changing because of their general medical or biomechanical
Are orthoses covered by medical plans?
Most extended medical
programs (but not all) do cover the costs for podiatric
Sometimes these programs will pay the entire cost of the devices; sometimes
they will pay a percentage of the total cost--most commonly 80%. Sometimes
the patient has to pay a deductible for the year, then the plan covers
everything beyond that deductible; sometimes they'll pay the first few hundred
dollars in medical costs, but the patient must pay everything beyond that limit.
There are several types of coverage plans, so if you have a policy, you'll
have to find out exactly what it covers.
I will add, however, that
if a patient is covered for orthoses, most plans require orthotic devices be
prescribed by a podiatrist (D.P.M.) or a Medical Doctor (M.D.) in order for you to be
reimbursed. Quite understandably, extended medical benefit plans try not to pay for
inferior devices made by non-medical personnel and those in some sort of medical
field who are not foot specialists.
If you have no extended medical benefits,
the Ministry of Social Services (M.S.S.H.), the Department of Veteran's Affairs
(D.V.A.), Workmen's Compensation (W.C.B.), the Insurance Corporation
of British Columbia (I.C.B.C.), the R.C.M.P. and Indian Affairs all cover
orthoses on a case-by-case basis.
And if none of the above are applicable,
sometimes your employer will cover the costs of these devices, even when you
don't have extended benefits.