Prescribing arch supports complex process

Conway McLean, DPM

An employee in the paper mill, Rich had suffered from arch pain for years, although it depended on his duties each day. Rich had tried various supports purchased on-line, which did seem to help, but not very much and not for very long. He assumed it was a part of the job description, a burden he must bear.

A co-worker of Rich had no such problem, but instead experienced recurrent, mild low back pain. Prolonged standing worsened his pain, although it wasn’t crippling. Still, the pain he experienced absolutely reduced his quality of life. He had physical therapy, which helped, but only temporarily. Within a few weeks, it was “back” to normal.

These people, and so many others, obtained relief by the “simplest” of methods, by getting “arch supports”. Sounds so easy, doesn’t it? You could probably wad up some newspaper and have that work. (Believe me, people have tried.) But, as you may have surmised, it ISN’T that simple. Prescription arch supports are called foot orthotics, and are a frequent recommendation of health care providers. Where it gets interesting is in who designs the device? What kind of training is required to be able to prescribe a prescription device? The answer is none; any health care provider can prescribe them.

What does a foot orthotic do? They can do many different things when correctly prescribed. A typical goal is to alter the biomechanical function of the foot. Consequently, they also affect leg, pelvis and back function. This is an extremely complex topic, about which we learn more every day. The process of standing and walking, something that occurs repeatedly over the years, requires the use of many different body parts and structures, all working together in a carefully orchestrated but complex process.

Someone has some pain, and is told to get supports. Most will head to a shoe store or a department store and pick up some over-the-counter devices. For some, this is enough and no further treatment is required. Not everyone needs a prescription support to get relief of pain. But the difficulty with this approach is the number of options available. How is the consumer to know?

The process of fabricating a pair of customized, prescription foot orthoses varies tremendously. They are supposed to be formed from a copy or model of the foot. How accurate this model is varies greatly depending on the technique. Some prescribers will have you step into a box of foam, while others use a high-tech scanning device. The slowest, messiest method is with strips of plaster. This also happens to be the best, according to the top experts. When properly applied, the casting of the foot is so exacting, so precise, even skin lines are captured.

What is the prescriber’s training and education in body mechanics (aka kinesthesiology)? For many medical fields, little to none. Physical therapists have some training, while others consider podiatry to be the masters of the field. A goodly percentage of our education and training is centered around the study of the body in motion. Unfortunately, podiatric residency programs of late are not providing sufficient experience with this topic.

What if the casting is done with the foot in an excessively arched position? The device thus created would not be comfortable or functional. When the patient is lying on their stomach for the casting, gravity is helping the practitioner put the patient’s foot into the optimal position for gait, a critically important factor. Also necessary is the evaluation of joint motion and alignment, best determined with a biomechanical exam. This specific exam looks at the positioning and angulation of the important sections of the foot. How is the bottom of the heel situated relative to the ball of the foot, or to the lower leg? This can greatly affect foot, leg and spine function and should be carefully quantified.

Many clinicians only see the patient in a sitting position and never have them stand. It should be obvious much can be learned about foot and body alignment and function in this position. Perhaps even more important is a gait exam, in which the health care provider watches their patient walk. This is best done on a treadmill, with the individual’s gait recorded with slow-motion video, allowing the knowledgeable biomechanist to thoroughly examine every facet of how they walk.

Any discussion on the topic should mention the national success rate of orthotics. Far too often, about half the time, according to studies, they go unused or discarded, lost in the back of the closet. This reflects the tremendous variations in the concepts, methods, and materials used. If poor technique is used, inappropriate materials chosen, the efficacy of the device will be compromised. The result is a poor success rate.

Yet the benefits of a properly prescribed pair of foot orthotics can be phenomenal. From the aforementioned arch pain, to back pain, cramping of the calves, Achilles tendonitis, neuromas, bunion pain, shin splints in runners, knee pain, all these and more, are often based in biomechanical pathology, thus amenable to orthotic therapy. Some studies indicate orthotic therapy early in childhood can produce lasting structural changes in foot function. Kinesthesiology experts believe the consistent use of orthotics over the years reduces physical stress to the knee sufficiently to reduce the number of knee replacements needed.

Orthotics are non-invasive and so carry none of the risks inherent in a surgical procedure. They can be provided at a fraction of the cost of an operation. Even better, should the supports not be comfortable, or not function perfectly, modifications can be easily made by an experienced practitioner, leading to success. Perhaps now you can see why these supports are so commonly prescribed.

One of the most exciting advances in foot orthotic therapy is the plethora of materials for each and every part of the device. The flexibility of the shell of the device will depend on its thickness and composition. Where once there were few options for shell material, we now have many choices. A thorough familiarity is necessary to select the best for each patient. The days of prescribing a shell with no padding or covering are over

The science of orthotic therapy has certainly advanced over the last decades. We are at the point where different devices are prescribed for skiing versus skating, trail running as opposed to mountain biking. One study found slalom skiers could improve their race times by using custom foot orthoses. Many variations and modifications exist in orthotic prescribing, entailing notable complexity in the prescribing process. A typical pair of orthotics often requires three or more pages detailing the intricacies of the prescription, although many prescribers are unfamiliar with the nuances of the process.

As a clinician, I have seen the benefits of custom foot orthotics repeatedly. Properly prescribed supports can significantly reduce many painful orthopedic problems, even change people’s lives. Nearly every outcome study, regardless of what was being studied, has shown they work…..when the complex process of prescribing is accurately and correctly performed.

Is it ever a bad idea to have your car’s oil changed? It won’t hurt anything, and maybe the car will last a little longer. Similarly, not everyone requires a prescription device to obtain relief, but that will always be the most precisely fitting device, the most effective, the most comfortable. Avoiding surgery is not always possible, but prescription foot supports are a painless, easy-to-use therapy that can make all the difference, sometimes eliminating the need for an operation. If you or a loved one suffer from some painful orthopedic condition, see a specialist. Foot supports may be appropriate and can change your life. Does that sound grandiose? Perhaps, but then, I’m in the trenches!