Podiatrist Toby Thompson shares why orthotic therapy should be as unique as the activity and footwear it is suited to.
As podiatrists we understand the vital role orthotic therapy plays in addressing foot and lower limb biomechanical abnormalities. However, a one-size-fits-all approach may not always yield optimal results when it comes to certain sports. Each type of activity demands unique movement patterns, stresses, and forces on the lower limbs necessitating a tailored approach to orthotic prescription. Applying these considerations into our daily practice may help to achieve greater patient outcomes and improved comfort, allowing our patients to continue the sport they love and get back to it as soon as possible.
As I first began my journey as a podiatrist, my eagerness for knowledge and growth led me to constantly seek ways to enhance my expertise in orthotic prescription. While my enthusiasm was boundless, the realities of practicing in private practice differed significantly from my academic experience, presenting me with the humbling realisation that my university education had only scratched the surface of the vast realm of foot orthoses. I remember a conversation I once had with one of my mentors, which I still, to this day, reflect upon when it comes time to write a prescription for one of my patients.
“An orthotic is only ever as good as the shoes you fit them to, the activity you’re fitting them for, and the expectations you are trying to manage”.
Foot orthoses are designed in various shapes and sizes, ranging from 3/4 to full length, thin to thick, and hard to soft. However, it is important to note that the orthotic designed for someone’s work boots may not always be suitable for their weekend hobby of playing nine holes at the local golf course. Therefore, it is crucial to have a good general understanding of the footwear your patients wear during their desired activities. This can be identified through thorough subjective history-taking or simply by recommending that patients bring their shoes to their appointment. This not only saves a lot of hassle when it comes to fitting the orthotic but also prevents the realisation (when it’s too late) that the orthotic is too bulky to fit properly.
When designing an orthotic, I take several factors into consideration, including the narrowness of the shoe’s last, the depth of the heel counter, the pitch of the shoe, and the available toe space. Let’s use a football boot as an example. These boots often have a very narrow last and a shallow heel counter. In such cases, it is wise to reduce the bulk of the orthotic design by narrowing its width and opting for a lower-profile heel cup. You may even consider opting for a tapered arch profile to avoid the medial longitudinal arch (MLA) protruding out the side. After all, the last thing I want is for a patient to return and let me know that the orthotic skyrocketing the ball over the bar was the reason they lost their finals shootout.
We often use foot orthoses to help address biomechanical concerns, alter loads, and reduce tissue stresses[1]. We know that foot orthoses also help to improve energy costs during walking and improve physical function (medial-lateral sway) during stance[2]. Understanding the sport’s movements and the loading involved is therefore important. When designing a foot orthosis, I believe it is essential to find the balance between comfort and functionality. In my experience, the more complicated the orthotic is, the more likely the patient is to encounter comfort and wear-in issues.
Take running, for example. It’s not uncommon for patients to return with concerns over arch irritation and/or blistering after they have started running in a newly-dispensed orthotic. Certain design variables, such as the amount of rearfoot control, arch height, and contouring, may actually be aggravating factors. With the ground reaction force and centres of pressure increasing by 250% of body weight[3] it is important that these changes in loading are factored in. Certain material choices, such as EVA and Polyurethane (including PORON®), have been shown to reduce peak plantar pressures[4], improving comfort in high-impact loading sports such as running. With all of the prescription variables available to us, I still find that a ‘less is more’ approach has often helped me more times than not.
Managing patient expectations is something we do on a daily basis, requiring a unique set of skills to effectively communicate with our patients, which actually helps to improve overall treatment outcomes[5]. This often involves providing thorough and accurate information about treatment options, potential risks, and the anticipated results of the prescribed intervention. It is essential to address any misunderstandings, fears, or concerns that patients may have, offering reassurance and empathy throughout the process. At the end of the day, all of our patients respond differently to how they perceive the device in the first place. This may be their first orthotic or an update of an old orthotic with more holes in the top cover than a slice of Swiss cheese. Actively involving patients in the decision-making and design can build trust and enhance patient satisfaction. Additionally, regular monitoring of progress and follow-up review appointments help manage and adjust expectations as necessary, maximising patient outcomes and their overall podiatry experience.
Ultimately, with every prescription we write and shoe we fit; we all prescribe orthoses in our own specific way. I suppose there is no right or wrong way, but making the job easier with fewer hassles is something that I have always welcomed.
I hope I have helped shed a little light on some of the tips and tricks that have worked so well for me over the years. So, remember …
“An orthotic is only ever as good as the shoes you fit them to, the activity you’re fitting them for, and the expectations you are trying to manage”.
© Copyright 2021 The Australian Podiatry Association
