Orthotic Appliances)

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).  

Indeed, research 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. 

Orthoses are 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.  

But most people--even doctors--seem to use the word "orthotics" in exactly this way, even though it's incorrect grammatically.   

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's specialties.  

(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.  

One organization in British Columbia has individuals dispense $12 over-the-counter devices, yet actually charge as much--or even more--than true, custom-made prescription devices.  And 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 devices. 

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. 

A weight-bearing assessment and a Gait analysis, (a study of how one walks).................

          ......is 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.  

Most computer 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 position.  

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 appropriate device. 

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. 

What 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 specialty labs.  

But generally, there are several families of devices about which we may make some generalizations. 

Relatively rigid devices are 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 foot function. 

Rigid orthoses 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, but 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

Soft 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.

Semi rigid Orthoses are 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.       

Semi-rigid Orthoses 

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 foot). 

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.  




Pediatric orthoses 

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.

Other Types

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................ 

High heel pump: COBRA

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 troubles.  

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 condition.  

Are orthoses covered by medical plans? 

Most extended medical programs (but not all) do cover the costs for podiatric orthoses.  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. 





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The Achilles Foot Health Centre
S. A. Schumacher, D.P.M., F.A.C.F.A.S., F.A.C.F.A.O.M.  
Dr. S. A. Schumacher, Podiatric Corporation  

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