How to Evaluate the Orthoses Prescription

How to Evaluate the Orthoses Prescription
Arnold Ross, DPM
There are untold numbers of patients who are either unable to tolerate orthoses or who are not getting symptomatic relief from them. KLM is often asked to evaluate many of these patients and assist in improving the results of the orthoses therapy. The field surrounding orthoses and their application is highly subjective. To keep evaluations as impartial as possible, I use a three-point system for accomplishing objectivity:
Material
Fit
Correction
The Material
When assessing orthoses, look first at the material used for making the appliance. While the material must be rigid enough to support the patient's weight and control abnormal forces causing the problem, it must also be tolerable for the patient. Soft covers may be necessary, and in severe cases, softer materials may be used.
Orthoses Fit
Second in the evaluation process is examination of the orthoses relative to the contour of the foot. With the foot held in the neutral position, the orthoses is held softly to the foot and its shape compared to the shape of the patient's neutral foot. The result should show an orthotic that is closely contoured to the foot. If any gaps exist, the foot may pronate abnormally and this may create uncomfortable pressure points. Ideally, the shape of the foot and the shape of the orthoses should be identical. The only deviation should be in the forefoot, distal-medially for varus correction and distal-laterally for valgus correction Undesirable gaps may be the result of improper casting by the doctor or improper cast correction by the lab.
Cast Correction
Third, the amount of correction is studied. To check this criteria, the patient is placed prone in the chair, with the foot held in neutral by grasping the toes. The orthotic is then held to the foot and the relation of the anterior edge of the orthoses and the theoretical weight-bearing surface is examined These coordinates should be close to parallel. If they are not, the orthoses has either not enough or too much balancing. Although these are the three main factors for effectively evaluating orthoses, there are some minor factors that may also affect the patient's comfort and function. The most common example is arch pain. If everything is in order and the patient is experiencing abnormal arch pain, two things may be possible:
1. The medial edge of the orthotic needs to be lowered.
2. The patient has a tight medial band of plantar fascia and the orthotic needs to accommodate for it.
Certainly no single solution exists to solve orthoses problems. Utilization of this system for evaluation has, however, provided a solid basis for greater success in orthoses applications. If you have a patient who is not being helped by their orthoses, or if you would like to learn more about objective orthoses evaluation, call the lab. Our business is servicing your biomechanical needs

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Foot Orthotics for Diabetic Patients

Keith Gurnick, D.P.M.

The use of prescription foot orthosis is an integral part of the overall treatment in diabetic patients who have foot symptoms, structural or postural abnormalities, or are in need of foot protection to prevent complications due to the peripheral neuropathy which is often associated with diabetes. The selection of the type of orthotic is just as important as the exact prescription for the postings, balancing and other specifications. Just as the daily dosage, mode of administration, and selection of the appropriate antibiotic would be fundamental to properly treat a patient with a bacterial infection, the selection of the correct foot orthosis and proper prescription writing is fundamental in the management of diabetic feet.

Orthotic prescriptions for diabetic patients should involve not only the specific biomechanical considerations that all patients should be given, but in addition, those additional specific considerations pertaining to the musculoskeletal status, circulatory condition, sensory and neurologic status and in addition any dermatological considerations necessary for the protection of the individual patients' feet. Each prescription should be matched to the patient's individual needs. Additionally, special footwear considerations such as molded custom, extra depth or other "space" shoes might be required.

KLM Orthotic Laboratories has developed a totally new and complete line of prescription foot orthotics for diabetic patients with medically "at risk" feet.

These accommodative foot orthotics can be ordered and prescribed to address the specific individual needs for your patients. Each type of foot orthotic has specific indications depending on the requirements for soft tissue supplement, accommodative padding, pressure reduction off-loading of previous ulceration sites, support and control. Materials have been pre-selected to provide maximum shock absorption, reduction of shear forces and soft tissue supplementation.

The 5 different types of diabetic accommodative foot orthotics are listed and described below: They are each custom made prescription foot orthotics with different levels of control and soft tissue accommodation designed to relieve or prevent pain; improve or control abnormal foot function; redistribute pressure; eliminate or improve plantar keratomas; and reduce the progression of foot deformity and tissue breakdown caused by the effects of diabetic peripheral neuropathy and musculoskeletal changes.

Type 1 is made from a very firm black crepe shell and covered with a dual-laminate of soft pink plastizote over a Micropuff bottom layer. This could be ordered for the heavy patients or severe pronators and is the most controlling and durable but firmest in the line of diabetic accommodative foot orthoses.

Type 2 is made from a firm black plastizote shell and covered with a dual-laminate of pink plastizote over Micropuff. This is a controlling shell with accommodative covers and is lighter in weight and less bulk than Type 1.

Type 3 is made from a Multicork shell with pink plastizote over Micropuff top covers. This "midrange" accommodative foot orthotic will provide good support combined with excellent accommodation. Types 1, 2, or 3 could be suggested for patients with diabetic Charcot neuropathy.

Type 4 is much softer overall, utilizing Micropuff (blue) to build the shell and covered with pink plastizote over a Micropuff bottom layer.

Type 5 is overall the softest and least supportive and is made from a plastizote (white) shell and covered with the similar dual-laminate materials as Type 4. Types 4 and 5 are indicated in lighter weight patients with severe neuropathy who are less active on their feet yet still require some support and a lot of accommodation.

In addition to the 5 orthotic types on the order form, each practitioner can still "design your own" orthotic with any combination and thickness of the materials listed below, or you can choose any additional other materials listed on the order form.

TYPE	SHELL MATERIAL	LAYERS	CONTROL	DURABILITY
1	Black Crepe	1/8" pink pIastizote (top) 1/8" micropuff (bottom)	Firmest	Most
2	Black Plastizote	1/8" pink pIastizote (top) 1/8" micropulf (bottom)	Firm	|
3	Multicork	1/8" pink pIastizote (top) 1/8" micropuff (bottom)	Midrange	|
4	Micropuff	1/8" pink plastizote (top) 1/8" micropuff (bottom)	Soft	|
5	White Plastizote	1/8" pink plastizote (top) 1/8" micropuff (bottom)	Softest	Least

KLM uses dual and tri-laminates in the diabetic orthotic shells, top covers and extensions to provide maximum protection, soft tissue supplement and lesion accommodations with the most current "state of the art" orthotic materials available. Pink plastizote will provide the softest soft tissue supplementation and also take a compression set with use, while reducing shear. Enduro (KLM's Poron) will provide maximum shock absorption and reduce shearing forces. Micropuff forms a protective bottom layer, adds support and stability, absorbs shock and dissipates friction. These materials are each formulated to be durable, and are antibacterial, hypoallergenic also fungi-static to promote "in-shoe" good foot hygiene. The orthotic shell shape can be ordered standard size and heel cup depths, or can be modified to cradle the foot with medial and lateral flanges and deeper heel cupping to reduce plantar foot pressures.

KLM prefers semi-weight bearing impressions/castings for accommodative diabetic foot orthotics however negative non-weight bearing neutral castings are also acceptable. Tracings or other 2 dimensional techniques to imprint the feet are not acceptable. Areas requiring "off-loading" or pressure reduction should be accommodated with the foot orthotic. Lesions, ulcer sites or areas of boney prominence should be accurately marked in the impression or cast for exact accommodation by the laboratory.

The proper billing code for custom accommodative diabetic foot orthotics would be L3020. This code indicates a custom foot orthotic made from a 3-dimensional impression or model of an individual patient foot. The orthotic prescription by definition includes both a transverse and longitudinal arch.

KLM's full line of accommodative diabetic orthotics provide the treating professional with all of the custom orthotic options necessary to adequately treat the diabetic patient. If you have not yet tried any of the new diabetic accommodative foot orthotics for your patients, you are encouraged to order one. For questions about the different types or the materials, or which is the correct type to order for an individual patient, lease phone the lab and ask for a professional consultation.

About the Author

Dr. Gurnick is a consultant to KLM Laboratories. He is in private practice in Los Angeles, California, and practices Podiatric Medicine and Foot Surgery. He has a special interest in preventative diabetic foot care.

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