Allied Health Resources-Foot & Ankle Focus: Game Changers in Footwear, Orthotics, and Bracing

Foot & Ankle Focus: Game Changers in Footwear, Orthotics, and Bracing

Video Transcription

On behalf of AOFAS, I want to welcome you to the 9th webinar of the 2021 Foot and Ankle Focus Series.  Tonight's program, Game Changers in Footwear, Orthotics, and Bracing, will be moderated by Dr. Daniel C. Farber.  Joining Dr. Farber are certified pedorthists Denise Genese, Dr. Lance Silverman, Dr. Gary Stewart, and Dr. Michaelis Hogan.  You can find their full biographies and disclosures in the program document posted in the chat box and in the PRC.  The 2021 webinars are provided free to AOFAS members and Orthopedic Residence Fellows with funding from the Orthopedic Foot and Ankle Foundation, supported by grants from Arthrex  Inc. and Stryker. I'd like to run through a few housekeeping items before we kick off the presentations.  For technical difficulties, please try closing your browser and logging back in the same way you did the first time.  Registered physician attendees may earn one hour of AMA PRA Category 1 CME credit by completing an evaluation in CME claim form at the end of the webinar.  You can find the link to claim CME in the chat tab at the end of the webinar, and we will also follow up with an email at the conclusion of this broadcast.  This webinar is being recorded and will be available for on-demand viewing on the Physician's Resource Center at www.aofas.org in approximately one week.  We encourage you to ask questions during the presentation. To send your question to the faculty, click on the Q&A tab in your navigation column.  I'll now turn the program over to the moderator, Dr. Farber, to begin. Thank you.  Hi, and welcome. I'm glad to have everybody here. I want to especially thank all the panelists.  I'm going to share my screen briefly just to go over how we're going to try and do this tonight.  All right. So our topic tonight is orthoses. So we'll be talking about shoes and orthotics and braces.  We decided to do this in a little different way than maybe some of the other webinars have been done. We hope you enjoy this. If you don't, please let us know.  But if you do, also let us know. So as you heard, we have Gary Stewart with us, Lance Silverman, Mack Hogan, Dennis Gianese, and myself.  And trying to kind of have a broad spectrum of folks in terms of the patients that we  see and the way that we approach various problems. So we're going to basically present kind of a generic scenario, several different scenarios,  and discuss how we would approach this. Sometimes we'll probably be in agreement. Hopefully sometimes we'll have some disagreements about how we might do it or at least some  options and some real world experiences to kind of guide people's decisions about how to treat this in their own practice.  And hopefully you'll come away with this with one or two pearls or one or two things that you might do a little differently when you're back in the office tomorrow or whenever you  are. We definitely want to make this interactive. So please feel free to post your questions. Ignore where I said chat box. Put them in the Q&A box.  And I will try to monitor that as things go along and address your questions in real time.  And if you have suggestions, if you would treat some of these things differently, if you have  pearls to share with the rest of the people on the webinar, please throw those up there and I'll  read them out and we can discuss whether those are things that we found successful or whether that maybe you've got the next big idea in orthotics and prostheses. So have fun.  Please critique us. Enlighten us if you have better ideas. And so we'll kick it off with our first scenario. So this is a pretty common patient to see in the office.  42-year-old male with four months of great toe pain. Mostly localized to the top of the first MPP joint. Obviously worse with activity. Gets some relief with anti-inflammatories.  He's got a new job at the Amazon warehouse nearby. So he can't consider surgery for at least six months. So when he's able to take some time off. Maybe it's even longer.  I don't know how good Amazon is and things like that. So I'll throw that out there to the panel if everyone wants to pick this up first.  And how would you help this person in regards to shoe wear, inserts, orthotics, bracing,  amputation? I'll call Mac out on this one. Mac, what would you do for this person? My approach with this individual is when individuals respond well with inserts,  I actually use topicals as well. Pretty intentfully and across the board with my patients. So that's one piece. And obviously we're here to talk about beyond that.  And then I really start speaking with them directly about the type of shoes they're wearing throughout the day. Not just while working.  I look at it from a standpoint of minimizing the cycles on this early arthritis and just the patient's experience.  So deep, wide, toe box recommendations, providing them a list of those different things. And then from there, how stiff their sole is and what they're using to supplement,  whether it be a Morton's extension or something in the realm of an insert to address that or even a carbon fiber. And so those are the different things I recommend.  And see how we go from there. I think when we use the carbon fiber plates, just a couple of comments there. When you use that, if you use a full plate, which I actually prefer to a  Morton's extension, with a Morton's extension, if that's not, if you have a Morton's extension that fills the whole shoe, it works great.  If it's one that's smaller and it's going to slide around inside the shoe, you want to probably have it attached to the insole that is in the patient's shoe.  Because if it goes too far forward, it can cause all kinds of problems with metatarsalgia and other things.  And putting that flex plate in or carbon fiber plate in, you want to make sure that the patient is buying something with a shoe, even if it doesn't have a rocker  sole, it has a good toe spring. There still are shoes out there that are very, very flat. And if you put that carbon fiber plate in a shoe like that, it's actually going  to cause more problems. It's going to create a lot more pressure on that toe, especially dorsally, if they don't have enough toe spring in it.  But it's a good place to start for sure. Can you reiterate what exactly is toe spring for? Yeah. Toe spring is like a four-foot rock.  I mean, from the metatarsal, most of the shoes, most of the good athletic shoes out there right now, at the metatarsal heads, it will taper up to almost nothing at the toe.  So that's what toe spring is, like a rock on that forefoot. And you need that to replace the motion. If you put the carbon fiber plate in there, you're limiting motion.  But the motion has to come from somewhere. And it's going to come from the foot, the leg, the knee, whatever, if you don't have that motion built into the shoe.  And there's a lot of good shoes that have good toe spring on them. Okay. And the only thing I would add to what Dennis and Kalis have talked about was how I talk to a patient.  I tell patients they can get these carbon fiber foot plates pretty inexpensively from Amazon, but then they don't always fit the shoe perfectly.  So if it's somebody who's good with tools, has something they can smooth down the edges with after they use some shears, I kind of say you can get this on  your own and then modify it yourself. You'll get it for cheaper, and you'll do it for cheaper. But otherwise, I say to patients, just go to the orthotist, and they'll fit it  to your favorite pair of shoes, clearly choosing ones that have a better toe spring. Yeah, I agree, Lance. I think that in terms of speaking with your patient, that is very key.  You probably have similar patient populations. And some of these inserts can be kind of expensive. And so maybe being creative in how you can fit them into the shoe.  Because I've seen people come in, and they said, hey, Dr. Stewart, you told me to get this Morton's extension.  And then I find out that they're a size 5, and the Morton's extension is a 10. And I'm like, oh, well, let's talk about this more. So that's a great key.  Yeah, I definitely would say that I've had some even recent experience with patients having a lot of trouble getting these on their own and being able to modify them properly.  So I think it's always helpful to kind of give them that option. Because from an economic standpoint, that could be helpful.  But if they really want good fit and a good result from this, having them work with an orthotist or a pedorthist to do this right is going to probably have a better result.  A downside of it, I've seen a couple instances where people used them that they were too short. And the distal part of the Morton's extension actually ended up in the  middle of the great toe. It limited motion in the great toe. But because it didn't go out to the end of the toe, it actually allowed hyperextension of that IP joint.  And they ended up with a new problem. Because all the pressure was there when they were walking. And when you say trim them, I would rather have it too big and then trim it  to fit the shoe than have something too small. So I think that's a good suggestion.  Any other interventions that you would do for these sort of patients from a shoe wear standpoint? With these folks, somebody said before about a shoe that's big enough.  When they've got any dorsal bridging or anything like that, you want to make sure that you've got room for that.  And then there are some, I'm not a big fan of the over-the-counter rocker soles, but there are some good ones out there.  And if somebody's building a rocker, theoretically building a rocker sole into the shoe, it's probably going to be fairly stiff to begin with. So that is an option as well.  I've told some patients that they can go to get their leather or softer shoes stretched by shoe stretchers. Or if they have them at home. Some people do have those shoe stretchers.  And they are still available online. You can kind of push the knuckle up right where it is. I tell patients, I say take your wife's or take your own least favorite  lipstick and color it on the top of the bump that hurts. And go walk around in the shoe and go see where the lipstick transfers.  And then just use that as your marking spot to where to put the shoe stretcher. I think that's often important in this situation is to sort out.  In this scenario, it was motion that was the issue. But for some patients, actually, motion is not the pain generator. It's just the prominence over the top of the foot.  Sorting out the difference there will help you. You may not need to go to a flex plate just because you see the arthritis on the x-ray.  You may need to do something along the lines of what Lance is suggesting or just having them get a soft upper shoe.  And it's surprising how many people haven't figured that out on their own. Most seem to, but some don't.  For many, they just don't want to accept a different type of shoe than they've been wearing for many years. But that's, I think, a helpful piece.  Well, they do fine in summer when they can wear sandals. It's just when winter hits. In Minnesota, we've got nine months of winter and three months of really bad ice fishing.  Well, here in Georgia, it's a lot different. The complete opposite of that.  Sometimes finding people that they want to wear their flip-flops and it's the motion of the great toe that is giving them pain when they wear those  little flimsy flip-flops or sandals or what have you. And so combating that with some options that are still comfortable and fashion-wise is important. Great.  Another stage advice for participants. Please, out there, if you have some suggestions for us or things you do differently, throw them into the Q&A box.  And we're happy to answer those. Okay.  All right. So let me go full screen. There we go. All right. Well, let's move on to the next thing. So here is a 58-year-old woman with several years of progressive midfoot pain.  She points over the dorsal midfoot of her TMT joints, which you can see on the film there. It's the worst area of pain.  And she's on a lot of medication. She's on a lot of gel, but she just, you know, she can't, she wants to travel. She can't walk very far without a lot of pain.  She's got three cruises set up in the next few weeks. And she's unvaccinated. And so she can't, she can't.  And so she's going to be a little bit warm. Can you tell us a little bit about what you expect at first? Sure.  You know, initially I would think of, you know, she's going on cruises. And so she's, it's going to be a little bit warm. So it's telling her to wear. A shoe that is wide.  and thick-souled is not going to be something she's going to wear at all, or anyone would wear at all on vacation. And so I would think of, you know,  obviously the anti-inflammatories and topical stuff that we talk about, but I would think of something almost as, there's some sandals out there that have kind of a soft top  and a stiffer sole with padding, almost like a wedge, but not a wedge, but just thicker sole that can be stylish and allow this patient that has this midfoot arthritis  and the tarsal middle tarsal joints to ambulate on vacation while still wearing some vacation type of shoes. And so I would think of a kind of sandal  with almost like a soft cottony top, stiff-souled shoe, but with padding. Now, that would be an example of what I'm talking about. Now, the other shoe, of course, you could wear,  but I guarantee you, if you tell someone to wear that on their cruise line or here in Georgia, they're gonna sit right in their, these shoes are gonna sit right in their closet.  And so by textbook, this would be the shoe that you'd wanna wear with kind of a rocker bottom, maybe even a little bit of a double rocker where you have a very loose vamp  and a deep, wide toe box. That's something that would be great in Minnesota as you're getting ready to go ice fishing, but, and this is a realistic shoe,  especially if you're somewhere where you're in air conditioning or inside. But if you're gonna be in Georgia in the summertime and are nine months of heat,  it's just gonna be really kind of impractical. The patient is not gonna wear this. And so that's why, you know, yes, a rocker sole,  but then the previous picture that Dr. Farber showed would be something that I would suggest as an option, at least have someone be able to wear that.  And you can see where those are, you know, they have a nice kind of rocker to those as well, just like the shoe, but it has some padding. It has a kind of a stylish top soft cloth  that can wrap around a bunion net or even a little hollux valgus or varus. And you can see where you have possibly the midfoot can be attached to the sole  and not be compressed and painful.  This lady does have midfoot arthritis.  Well, just to add on what Gary said, let's, you know, if we're gonna talk about the lady on the cruise, she's getting off the cruise and she's going on those hiking trips  in the cities that she's visiting. And she's gonna have something, you know, she's gonna have to have something a little better than that, depending on the terrain she wants to hit.  So I would be, and also for the rest of her life, I'd be thinking there's a difference between we got the sandal that was really stiff  and that horrible, you know, that I'm so glad I supplied as an option. But, you know, there's lots of tennis shoes out there that have, you know, the Hokas, the Skechers,  they have a rocker built into them.  You can add carbon fiber foot plates to people's favorite shoes that they've already found feel good, but I just will give them a little bit more stiffness  so they don't bend. But the final thing I've found for people, it depends on where their pain is. If they got that pain on the top of the foot,  right in the middle, and it's from the lacing of the shoes, there's a whole slew of ways that they can find online. And I've blogged about it once, so I thought it was really neat,  is how to tie your laces so that they don't run across the areas that hurt. And so you can look up lace tying options and just change the way the shoes lace  to stop some of that bump and rub.  I think for that midfoot prominence, the easiest one, and I agree with you on the laces, but the one that, the logical one is just to skip a couple eyelets.  You just lace underneath the same side, and you can, depending on where you skip a lace, you've given them instant relief for that dorsal prominence.  It's like magic, and people can't believe  that they never thought of it themselves. So to just skip laces is a good place to start with that.  Don't wanna spend a lot of money for these people, but with the sandals, we can modify them as well and put a real significant rock on it. So regardless of what they wanna wear,  I tend, I've got some shoes in my facility, but I don't sell a lot of shoes. I would prefer somebody goes out and finds a shoe that they want,  and then do a little bit of a modification to it.  With this kind of a foot, a significant rock, always a flat spot, but a significant rock, the picture we looked at had some nice, again, toe spring or rock in the front,  but you want something in the back too so that when they come down, that's decreasing pressure on the back, and then you rock right straight through. And with that stiff sole,  you add a little bit of height to it. That can be done without anybody knowing that you modified the shoe,  and she can go on her three cruises with no problem. The other thing I add is there's a physical therapist who has chimed in on our question-answer, and most of midfoot arthritis  comes from either a first-rate instability and or gastroc contractures that can be involved. So getting somebody into a good physical therapy  calf stretching program can really make a difference. Getting somebody to do some peroneus longus strengthening or intrinsic foot muscle strengthening can really make a difference  for patients that have found it as well. And to that- But, Dennis, or whoever else wants to ask it, we do have a question from one attendee  asking if the patient with first MTP arthritis should have a different type of rocker than this patient with the midfoot arthritis. Yep. If we're looking at first MP,  helix ridges or something, there you're mostly concerned about the forefoot. So it's something, there's about five or six different types of rocker soles.  So there you'd go with something that had a bigger, a better mid stance, and with all the rock in the forefoot, and you bring the apex of the rock  right behind that first metatarsal. Typically, we would come back behind all the metatarsals. But if we're just looking at that first,  then bring the rock, bring the apex of the rock right behind that first, with a real significant four foot rock, and that replaces most of that motion.  Good question.  Well, there's somebody who asked the question about adding a carbon plate to the rocker. The rockers are pretty stiff in my experience. Dennis, am I right there  with those rockers are already stiff? They already don't need it. A lot of them are stiff, but to be honest, what we do, if we've got somebody that really needs  a very significant rock, when we're modifying it, we actually will use a carbon fiber plate or a spring steel plate in between the sole.  And with the carbon fiber and the spring steel, you have some give, so it actually helps propel, but it makes that rocker even more effective. Would you write a prescription?  How would you write your prescription for what you're saying? Or do you just see the patient for midfoot arthritis, and we've written a prescription for a type of just a shoe  for end diagnosis midfoot arthritis? What would you like us to write so you can do that? Well, I mean, probably if you say, you could say extended steel shank,  or if you say rigid rocker sole, rocker sole is rocker sole. If you say rigid, then the practitioner is gonna probably know that they've got to put something in there  to really make it rigid. And the rocker sole, I fudge on adding the shank and the steel shank or the carbon fiber plate in the sole because it's expensive,  but you get a much better rock. So I mean, you make the sole stiffer by adding extra material to it, but it's amazing that shank in there, you get, it's so much easier  to get a real, real effective rock if you stiffen it up.  If they only had this trouble on one side,  what do you do with the other? Yeah, you rock, you need to rock both of them because you're increasing the height. On the unaffected side, you don't need to worry about the shank.  And you can do, you don't have to do as aggressive a rock on the unaffected side, but you need to raise both sides or you're gonna create a leg length discrepancy.  I think there's a great question regarding a double rocker for a midfoot arthritis to offload midfoot arthritis. You know, some of the shoes have a gentle double rocker,  not like the ones you see in some of the articles. What about you, Dennis, when you have someone with midfoot arthritis, what do you like to see?  Well, I mean, there's a lot of discomfort there. I've got one position I'm working with right now, sort of a new relationship. And he has sent me this patient numerous times.  We're not worrying about a custom foot orthosis. I love to do custom foot orthosis, but I am just doing a rocker sole on basically any shoe they bring in  with a nice four foot pine foot rock on them. I've had people that just walked around the office after they put it on and said they no longer have pain. It's unbelievable,  but it truly can take care of that pain. But always remember, I'm not talking about a rocker chair, you know, a rock like that. You've gotta have a mid stance there,  or these people can't, especially when we're getting into, as we get into the older population, there's gotta be a mid stance. They've gotta be able to stand.  And, you know, you think back, Skechers and some of the other companies had the rocker soles and they were gonna, you could lose weight and get better looking thighs  and everything else from wearing them. That's because it was, there was no flat spot whatsoever. So when you were standing on those things, you were very erect  and you were continually using your muscles to try and stand up. That's not what we're talking about for this problem. But you need, in this picture here, that picture we just saw,  I'd like more rock on the toe of that one, on the heel of that one.  We'll move on to our next scenario. I think we covered a good bit of the different things so you can approach this with us if anyone has some last comments.  But scenario three. So here's a 34 year old male with non CMT,  cavus deformity,  complaining of pain along the forefoot and lateral fifth metatarsal with prolonged walking and standing. He doesn't fully correct with Coleman block testing,  but he's got some hind foot mobility. He's not totally rigid. So,  Mac, how would you address this? Yeah, I mean, this is what a number of us see. I'm sure we have a similar patient population in this regard. And when their arch is this high,  it's non CMT, I like to look at this and say, okay, you likely have a variant of CMT we just don't know about yet, or that no one's ever,  they don't have the genetic testing to confirm that. But, and this is the patient also with their cavus, more metatarsus adductus. So my approach with these individuals,  how can I accommodate them? This individual is probably very active. That's why he's feeling that forefoot and lateral fifth metatarsal loading with standing. And so I will try,  an arch rival is something that can reverse, but it's not going to correct something like this.  In my experience in totality, the arch is too high. You mentioned it doesn't fully correct. However, it can get you there a little bit. I talked to them about a wider shoe,  some of the same shoe stretching concepts we mentioned previously. And then based on where their pinpoint tenderness may be,  sometimes I'll even just offload them with a reverse dancers. I'll take a dancers pad, reverse it and strut their lateral foot  and basically have it where the fifth metatarsal is somewhat suspended and tell them to go into one of those different shoes and ask them how they feel with that.  Some get, in my experience, some individuals get relief because it takes the pressure off the fifth metatarsal that essentially bursitis that they've developed along that column,  as long as they're negative for a stress fracture or any other type of pathology. That's usually my additional approach. And as those things may fail, then I take steps forward  and more extreme custom orthotics are in that direction.  What I like to do, Mac, is to kind of piggyback on what you're saying, because that was an excellent approach, is sometimes I just look at the shoes they have on.  What I find out is that either they have been wearing a shoe with a big medial arch support or an orthotic that someone has made improperly trying to build up to the arch,  which is the wrong thing to do. And sometimes you can go into more of a new, even if they're in a neutral shoe, even someone like this,  because they've been working towards this for a while and just going to a more neutral shoe, almost like one of those Hoka type shoes or something like that,  that although it has the padding, it does not have a big arch support, like say your Brooks or something like that with a big roll bar. And so I've had patients that look like this  and you see the X-ray, you're like, oh my goodness, we're gonna have to do something to correct this surgically.  And you look at their shoe wear and you realize, oh, we just need to take that bad orthotic out and get them a more neutral shoe. And they are happy.  So yes, this is kind of a different problem. We also need to be very, in this particular scenario Dan's created, it's putting us into trouble because we're talking about orthoses  in the condition that if you sit this patient at 34 and he's walking around and does this, he's gonna destroy multiple areas of his foot because he's so out of biomechanics.  And we can do all we want with orthotics here  and posting and lateral flares on the heel and lateral offsets trying to stop things, but it's blowing into the wind in the long run. So I wanna keep,  I know we're talking about orthotics here, but we have to have the conversations with the patients too that say, we're gonna try to do this just as a non-surgical management tool,  but eventually you're gonna need something more.  Dennis, what are your thoughts? Well, there are days I changed my practice and I'm in a small town, my hometown, and the people that wanna come to me have real significant problems.  So I've got people coming from hundreds of miles and there are days when half of my practice is cabus feet. I mean, it's just unbelievable. And for a multitude of reasons,  obviously CMP, but I can go through and I'm not gonna waste time on it. Actually, I'm doing a poster at the summer, at the annual meeting. So take a look at my poster.  It's like cabus feet, but I'll do a little ad there. But I think that what so many people miss  and I'm not saying you guys, it's the practitioners that you're going to. And we talked a little bit about it here is the forefoot.  You know, you hear it says it didn't fully correct  with that Coleman block test. So many of, and you know, it's non-CMP supposedly. So maybe it isn't a real severe case. I'm seeing the worst of the worst.  And I focus on that forefoot posting. And it's just amazing. Let that, I literally in the orthosis, I will make a depression. I'm making all my own stuff now.  I'm not central fabbing it. And I actually let that first go down and I post the forefoot and you can do so much correction with it. I'm not saying that's gonna last  for the rest of their life,  but you've got to address the forefoot. The forefoot is just such an important part of this. The heel isn't gonna make much difference. And that's why the Coleman test,  now you said it didn't fully correct it. So that means, and there's a lot of different kinds of cavus feet. I mean, there's cavus feet that just have a high arch  and you don't have any forefoot or hind foot. The heel may not even be in any varus. It's just got a real strong foot and a high arch. You have to really look at the cavus foot.  And I think that's why I see so much of it  because people really don't understand what to do with it. And so you've got to, each one is so unbelievably different. I find that people that I've got  have so much problems with the base of the fifth metatarsal.  And that's a lot of times, that's as much of a problem as anything. I do like, I use semi-rigid. I don't like to use firm materials. I use semi-rigid cork posting type stuff.  Come up to the arch, but you've got to allow it. It's not that you're, they shouldn't be walking on the arch. They shouldn't be pivoting on the arch,  but you want to distribute the weight evenly. And then with that forefoot posting and then relief for the certain areas. Some of mine look really funky.  I mean, they've got a depression under the fifth and under the first fifth base and the first metatarsal. And you look at that and it's a very complex device,  but it really works well now. Is it going to last them 20 or 30 years? I can't promise that.  I appreciate we have a question in the Q and A about the Coleman block test. And one of our participants was kind enough to explain that.  But briefly, if you're not familiar with that, the idea is to essentially create a floor and then drop the first ray below the floor and see if the hind foot is flexible enough  to correct the hind foot varus. And then you know that the forefoot, but the cavus is driven by the forefoot position. And if you address the forefoot as Dennis is talking about,  then you can pretty fully correct the hind foot position and that will help them with their overall biomechanical balance. So in a foot like that,  you could probably get some long lasting support with the right insert. But when they don't correct, it means that there's some rigidity in the hind foot,  which can come from the type of cavus that they have or can come from a tailor arthritis that may have developed over time  or even ankle instability that may have developed over time.  So I want to just add one thing on that, Dan, and this goes to what Lance was mentioning. These are the patients, even if they're young, a mentor of mine a while back,  I mean, many of us know him. I mean, Shep Hurwitz used to talk about, these are the patients who are healthy, active, you know, they have the tired foot that he would monitor.  He said, you know what? You probably should come back and see me in a year, nine months to a year, just so we can kind of check and see how you're doing.  Because of the point that Lance is making, I mean, you try these non-operative approaches, you hope they are doing okay for a while, but you know their biomechanics of their ankle  and their foot motion is just not normal for them. And monitoring them can help you try to stay ahead of them, which, you know,  and it's just something to think about in this population. And so I will tell them, you know, just check back in with me or give a call is one of the approaches I will take  if they're not ready for a broader surgical discussion. I think that's an excellent point. With 30% of the population going diabetic,  letting these come in with the ulcer that's been whittled on and a part of the brain that's been excised, because it leaves without a perineus brevis now,  and now, you know, cuboid osteo and it's all over. So just trying a calcaneus osteo and then the leg's gone. And I see these commonly like that.  And I just, you know, it disturbs me to see the whittling. So if you find a 34-year-old, getting to them before they get whittled upon  is really important and following like Michalis said, I think that's a great idea.  That's great. I think one of the also takeaways, just we were talking about quite a bit earlier is that fight that urge to fill the arch.  Patients want you to do that  and they'll say, I got this great arch and it feels so much better, but you're just accentuating the deformity and you're not allowing the foot to correct.  So I run into that a lot where patients don't, and again, some practitioners don't understand the concepts behind what you're trying to do.  And so a big arch doesn't need to be filled.  Right. If I have a patient with this issue, even if I write the orthotic, I actually have them have a follow-up visit with the orthotic because,  Dennis, I wish I could just transport you or somehow have you fill my orthotic prescriptions, but we don't make them in-house. I don't make my own in-house. And so quite frequently,  I write a prescription for a subtle cavus foot orthotic and I'll write specifically what I want, non-aggressive arch, a depression under the first ray,  some lateral posting, as you can see here is the one, this is actually one of my patients here. I'm trying to show my subtle cavus foot orthotic.  And it really, I just can't seem to get them back. It's like two or three times. And I don't know if this, they continue to fill the arch up and the patient becomes frustrated.  These are expensive orthotics. And so what I do with this type of patient is I will get a subtle cavus foot orthotic as I described. And this person does have some heel virus.  I hope you can see that, but you have to be careful with the shoe you're gonna put them in as well. And I have found, and I know we're not supposed to say a lot of trade names,  but I don't know any other way to let people know what we're talking about. But I found that the Hoka shoe has good padding with a more neutral portion of the shoe.  And so you can add a subtle cavus foot orthotic after you take their padding out. And sometimes they're really happy with this. Yeah, and a thing you have to think about  with the shoes as well, the Hoka is great. I mean, it's really popular now and I think it deserves that. But a lot of these folks have a little bit of Aquinas too.  And so many of the shoes now are going to minimalist. I mean, there's no counter in them, but they're also lowering and lowering the heels.  That's gonna be counterproductive for this patient. I mean, we don't want a high heel, but you gotta have some heel there because unfortunately they end up,  and a lot of them end up in a little bit of Aquinas. So you can't go to this.  Eventually, I mean, I think some of the companies, they just wanna put a piece of cloth around the foot  and a lot of our people need more support than this.  I think that's a good point that Lance had touched on earlier is the physical therapy aspect of this. So no orthotic is gonna be successful  if they've got a really tight Achilles or gastroc. And so a big part of this, and sometimes I will send them to therapy to work on stretching before ordering the orthotic  so that we can see if they can get a little more flexibility because the orthotic may not work if they're too tight, not as much in the cavus as in the next scenario.  So let's move on to that.  So I gotta move my little windows here. So here's a 47 year old female with a bilateral flat foot symptomatic on one side, not as much on the other.  Pain over the posterior tibial tendon for about six months and now starting to notice a little lateral pain. She tried some super feet that she found over at Dick's Sporting Goods  and tried a brief that she found there as well, but it hasn't really helped that much. She's tight, as I was just talking about,  and she's here for some help.  Mac, you wanna?  Yeah, I mean, so- Do I keep picking on you? I feel like I just keep picking on you. That's probably because my photos is right under yours, at least on the screen.  But I don't mind, at least it's all good.  So, we all see this patient, commonly,  and it's a very real problem, right? I mean, the posterior tibial tendon insufficiency  and what is going along with this is all the things we've already talked about, right? Lateral column overload, again, that sinus tarsae type pain, location pain.  Their gastroc is tight because they've been in this position for a very, very long time. Their gait is starting to shorten in their stride, and so now they have an ataxic gait,  and then their gastroc is getting even tighter. So, all of these different things. So, the physical therapy pieces, we've hit on that. A well-stretched gastroc has a lot of value  across the board, across different pathologies. But I do like to start with non-custom orthotics.  And a lot of it is, frankly, again, one, we don't have the expertise that we have here tonight. I'm like, Gary, I wish I could transport them into my office.  But the frustration with the cost of when orthotics do not work as well. I would rather try a series of different things.  Amazon, you can get them online. I personally use the Pinnacle, which is a good brand, and the Pinnacle Max, or the Pinnacle, it's like a blue or maroon.  I should have sent a picture, but, and the cost is not prohibitive.  And then I'll do different things with posting in different areas. A remedial posting to really try to open up that sinus tarsi, kind of slide that heel a little bit  and not be as drastic. And then placing them into some of the different shoes that we've discussed for that support. Particularly, they've already failed at ASO.  That's my first round approach in this regard. And I will even go as far, I know we didn't talk about it before, but I will go as far as giving these individuals  a night splint and tell them to alternate either day to day, which one they use it on, or one week wear it on one side, the other week wear it on the other.  And people hate sleeping in those. No matter, there's no night splint that individuals wanna wear for the rest of their lives. So what I tell them is instead of sleeping in it,  when you're sitting around watching TV, doing your gaming, doing your Netflix, your word puzzles, whatever you like to do, just wear it then. And you'd be surprised how many hours  they can get in a day of using a night splint  and actually not fighting with it as they use it at night. So that's the approach I take with these.  If you use that night splint, I've taken to calling it a resting splint. Yeah, I like that. I've tried to wear one a couple of times, and doctors are the worst patients.  And I had to just resort to wearing it awake, like you said, because it is very tough, but it does work. And I do believe that physio can stretch our gastroc  as well as our Achilles. So I do believe that a good physical therapy program with focus to that area will help.  I agree. I think that there's a lot that physical therapy can really make a huge difference with, not just the stretching, but trying to improve what's causing the problem.  And if you go back to a SIG Hanson's kind of concepts here, we got an underactive peroneus longus and strengthening that strengthening, some intrinsic foot  muscles, uh, teaching people, those things can give people a lot of foot comfort, uh, you know, and, and, and help them prevent further collapse.  We've talked about some of the basics. Um, I just put on here as some longitudinal metastatic support, scapoid pads, things like that, simple things that you can kind of get people  at least started with something for, for, uh, you know, as a trial, um,  uh, and ask folks, uh, what, what, what's your role for custom orthotics, uh, in this setting.  Yeah. I mean here, I like with that, with that foot, I like to get a lot of heel cup and it, I'm using something like this semi rigid, but still you can make a high  heel cup and of course people put it on the floor and they step on it and it's like, well, that flattens out. Well, we happen to wear those things in shoes.  We don't wear them, uh, taped to the bottom of the foot. So you, you get a nice heel cup and if you can control the heel, you've  got a little bit more of a chance of, of controlling, uh, the rest of the foot.  For some of those more severe, yeah, something here, I like, I like a nice high heel cup, but it's hard to see on that picture of mine, uh, and that  will really help control the heel. That, that, that's a good place to start. And with some of those feet, it's sort of an old fashioned way.  And again, you, you, you commented on, on the orthotics and the customer orthotics, so much of what we do today is it's, it's, it's all central fab.  A lot of people are not making their own orthotics, which is obviously the downside. They don't really, the lab doesn't really understand the foot, but with  some of these folks that we're talking about right here, you can do a medial heel wedge and then do a lateral.  Uh, four foot wedge and that actually, those two put together actually really helped to bring that arch up and take some of that, uh, stress off that postive tendon.  We have a question about, uh, for a medial high foot pain along the posterior tip, if you use arch support or an ASO or combination,  one or the other, or both.  Um, I I'm very transparent with this, you know, based on their demand. Um, I, in the patient, I will sometimes load them up with both.  So if I have someone who is a laborer or someone who wants to do a lot of yard work, I talk to them and they say, well, I really don't want to wear a working  boot, which gives them some ankle support plus the arch support. I will give them, uh, both, uh, a non-custom support and, and say, Hey, an ASO.  Um, and, um, and, and I tell them to play with it, right. You have different things you'll use for different scenarios.  If they're working in their yard, it's very hilly, uh, that may work for them, uh, and, and really, you know, strap it up tight.  Uh, and also that gives them a little bit of play based on what shoes they may have at home at the time, um, prior to me taking a step to a custom brace.  But again, I mean, no specific science to that, but I believe patients and you educate them and speak with them. They actually enjoy having that.  Um, disease state and their problem, uh, versus kind of, you know, rigid, fixed, et cetera, and this is going to be it. So, um, that's the approach I take.  So the OIP answer for this sort of thing is often a modified UCBL thoughts on, on this, uh, device.  Yeah. I mean, you know, uh, this is the one, uh, that, uh, that, uh, that, uh, that yeah, I mean, you know, uh, this is the one when I was training, uh, with  when in Philly, you know, this is our article and we would always talk about it and I first came out in practice and started trying to use it in goodness. Gracious.  I mean, people did not, they just didn't like it. I mean, it may work for the, that particular study in the paper.  And so, but, um, I think that, um, I do use it's mentioned in one of the, uh, the Q and a, there is a particular PTT D strap brace that is a little bit more  specific than the ASO that is much more comfortable than the OITE question answer. Um, although that is effective.  And so I tend not to write these cause it is, it is relatively expensive and I give them kind of that cough brace that will provide some support.  And we realized, and I'm clear when we get them to call phrase that this isn't going to cure anything. I do believe that physical therapy to strengthen the posterior tibial tendon  and intrinsic muscles as Lance and I both learned. Uh, and so I will do that. I'm a big believer that, uh, some mobilization rest, physical therapy and  some anti-inflammatories, um, will help with kind of a simple issue of a posterior tibial tendon dysfunction.  So how often are people going to the Arizona brace? Another OITE answer.  So I'll tend to use this on the very heavy patients who are sent, who are sensate, not the insensate ones, but our sensate, the insensate ones.  Um, unless I really trust the orthotist that they're getting it from.  Uh, I'm very careful. I don't want to have them get a, an ulceration, but, uh, you have to know you're, you have to know what that's capable and it's the really heavy, big  people may, and I'm going to generalize to males here that'll even look at this and say, oh yeah, that's what I want to wear every day, but I have seen a couple  of, I have seen some elderly females agreed to do it in Leah of surgery or with failed surgeries, and they just do not want to go back under the knife  again and don't think anything's going to work.  Uh, I mean, this is still in my wheelhouse. I mean, I, this, or sometimes even a Ritchie brace, but a Ritchie type brace,  but, um, I, I use it for the same patients is, is meant to the Lance mentioned. Uh, I believe it definitely goes with just education in regards to their disease state.  Someone comes in with me and they have posterior tibial tendon insufficiency, or from the beginning, I give them a, a writer, a printout about their disease  state, right, and you always have the same discussions I've lived my entire life. No one ever told me I was flat footed, you know, even though they can look at  their feet and tell that they're like pancakes, but it's okay, you know? Right. So it's part of us having an educational experience and, and bonding with them.  And this brace and a series of braces are in the handout I give them. So they know it's on the spectrum.  And then, um, uh, and some individuals, as Lance said, they, they really do not want surgery.  Um, and if you have an orthodist, uh, that you work closely with, uh, I trust our team, uh, and they'll work with us in modifying this. And there are some who'll say, you know what?  I want to wear this until I can't wear it anymore. Particularly once they read that handout and they know the recovery from, uh, uh,  some of the complex Hanford surgery we do for this can, it could really be 12 to 18 months. Um, so, uh, and that also gives them information on therapy  and Alvarez protocol, et cetera. So, uh, it is still in my wheelhouse. I can be archaic in that regard, but, uh, some patients take it and love it.  Others will throw it at you when they come back in. Uh, and they'll say, why would you even think this would work for me?  And I go back to the handout and say, well, the picture was in there, did you read the handout? And they say, yeah, I did. I did. I, you're right.  And we've been a handout and you can have a lot of variations of this as well. I mean, this was the basic Arizona. This was, this was the, the original, but, uh, you can get this  brace with an articulated ankle and, and maybe you don't have to lock up that ankle, you want to control it, but you don't necessarily have to have to  mobilize it so you can get an articulated, uh, Arizona brace or Arizona type brace gauntlet. Uh, and then there are some, some short versions of this more like an SMO, but  it, it, if you go to the shorter version, even using it in place of the, uh, the UCBL, if you go to that, you can have a softer plastic, it's not as bulky.  Uh, and it's laced on.  So you get so much more control out of that than you do from your UCBL or a regular plastic AFO. So, you know, this concept is good, but there, it work with your practitioners.  Uh, there's, there's other versions of this that, that, and, and actually make it make that patient a lot happier. This of course is an issue.  It's on their right foot and they're driving.  Uh, it's hard to drive with this. Cause you can, you're used to using your foot to drive. So they've got to use their leg to drive. Uh, the articulated may be fine.  You may be able to, to let them use their ankle some. And so just when we say that, just look at different options because there are different, different ways you can go with this.  We're starting to run low on time. We have one more scenario that I'm going to put up kind of, kind of quickly here.  Um, and really just to say, would people do anything different than some of the things that we've already put up there?  So this is basically a 64 year old female with, uh, early ankle arthritis.  Um, you know, she's got some relief. Uh, she can't get a corticosteroid, some relief with anti-inflammatories  had a bad reaction to steroids injections. So she doesn't want that. She doesn't want surgery because she's caring for her elderly mother.  Uh, some of the things that we talked about earlier, Arizona brace certainly can be helpful along these lines. We also talked about the rocker soles.  Um, and, and that can be also helpful to take some of the stress off the ankle. Um, any specific things, uh, that the panel would do.  And then I wanted to go kind of do our, our, uh, round table of, uh, kind of our game changer things after that. And then we'll wrap up.  All right. I think you hit it, hit it on everything.  Awesome. Well, it depends. Like sometimes if you have a patient here, double upright AFO can help because you can transfer so much more of the pressure from the foot through those  metal bars, uh, up to the middle of the leg and trying to get like 25% or more of that body weight to transfer if possible, uh, patellar tendon bearing  orthoses, if you have somebody who's super dedicated to avoiding surgery. Here you can do PTVs kind of thing.  That's even more, um, takes a lot of talent and the, uh, uh, orthotists, uh, are still training. They're just not using these as much as they used to.  All right. So we're going to go on to a game changer. So basically I'm gonna go around the horn. I'll start with myself and then, uh, um, I'll just pop everyone up and you  can give a couple of minutes, uh, commentary on some things that really, uh, I asked the panelists to sort of look at what, what's made a difference  in your practice or what's something that's really a go-to, uh, of, uh, orthoses. So, um, uh, so, so mine is a Maso for Achilles tendonitis.  And, uh, this is something I learned, uh, when I, um, moved here to Penn. And so I have to credit, uh, Keith Wapner and Wen Chao and, and, uh, probably  Paul Heck before them or with them, maybe, uh, with this idea. So it's not my own, but, um, this is something that for patients to come  in with kind of long standing, uh, or moderate standing Achilles tendonitis.  And normally you'd put them in a can booth. That's what I was always taught.  Um, and this device is, uh, really helpful. It's in the, it's in a little bit of a, of a quietness or take some tension off there.  It's got to blow out along the back of the Achilles so that they don't get pressure on the tendon and it's a great way to, to more functionally immobilize  them, they could wear it with a shoe.  They can hide it under a pair of pants, um, and they can use it throughout their rehab process. So this has been something I've found super helpful, um, in, uh, in  settling down a lot of patients with Achilles tendonitis and patients are pretty accepting of this for the, for the most part, I'm going to go to  Lance, uh, with, with big stuff here.  Uh, the IDEO brace. So I had a really awesome experience down at, uh, the center for the intrepid, uh, and the army hospital down there, uh, several, more than a  decade ago and was introduced to this brace that they were using to, instead of, uh, amputations to do limb salvage in these mangled lower extremities or  people with severe post-traumatic arthritis. And, um, since then I've attempted to get patients to get these.  It's been definitely possible with work comp, uh, and, and, and, uh, a third party injury claims, personal injury claims, um, and insurances are starting to allow versions of these.  They're expensive because the materials are carbon fiber, and it's a very expensive and technically challenging thing to make.  Uh, but the orthotists love to do it. And I've seen the athletic thin male up to many, you know, uh, you know, up  fifties and sixties, even there, or even the heavyset males really get a lot of benefit from this because of how much pressure is taken off the leg and  transferred up into the calf and the knee.  All right. So Gary, you, uh, yeah, we talked about this, but anything you want to add in terms of the subtle cave, it's orthotic.  Well, you know, I find that like we were talking about earlier that it's just getting a little bit harder to, to get someone to make this properly.  Um, but you know, when I have a patient and I'm able to, you know, get them this proper orthotic, um, in with the proper shoe combination, something that doesn't  have a high arch or something that's not too thin, uh, the patients just love it. I mean, they kind of just come in and, uh, uh, say, well, thank you.  If it was that simple and it's not for those big cavies deformities that we showed earlier, but something again, a little bit more subtle, if you can have  the lateral posting and you get the non-aggressive arch and you can find a way to give a depression under the first ray, um, you can really, uh, give someone  some help and here you have more of a kind of plastic kind of, um, makeup, but you can even do some of these with a kind of tri-laminate approach with some  cork and plastazote, and you can really kind of, uh, give them something that's going to be durable as well.  And so in my practice, uh, if I can get Dennis to move on down here to Atlanta, we'll be all set. It really helps.  I don't know about Atlanta.  I like a little bit of winter.  All right, Mac, you chose the, uh, air heel brace. Yeah. I mean, this is, um, you know, some of you have likely seen this, um, it's  off the shelf product that, you know, are, uh, the company we contract with for DME and our offices, we, they carry this, um, it is, uh, you know, was a  billable brace with insurance, uh, for certain diagnoses, particularly Achilles tendonitis, um, plantar fasciitis.  I've, I've used this for a number of things, even in the set of some of that lateral column overload we talk about, because this bladder that's built into  the device, uh, alone, the Achilles, if they have mid substance Achilles tendonitis, it can be helpful, but also to offload a number of things in the  foot, uh, plantar fasciitis, heel pad syndrome is not directly under the heel, but when they walk in the glide, uh, I found it to be helpful.  Uh, and I've even used this to offload, uh, an individual who doesn't want to stay in a boot and they're transitioning from, um, you know, fifth metatarsal  fracture or something that quite frankly is not limiting them, um, enough to put them in a cam boot. And this is a great transition device.  Uh, and so, uh, I gotta keep it in my wheelhouse to help for a number of different pathologies and I've had good fortune with it.  Are you finding that if you've, you've given a patient a boot and they had the boot code that commercial insurances or Medicare insurance is covering this  brace to transition to, are you finding that these are getting rejected? If it's within a, within a year period of giving them a boot.  Yeah. So, uh, so it's, it's a, it's a great question. Um, and I asked these types of questions of our, uh, of our vendor for DME and, uh,  it has, it has not presented an issue in regards to, uh, how they've coded bill for it. Now, again, uh, some of these individuals, I will say, you know what, can you just  use a firm shoe post-op shoe or something more supportive and then transition into this? So obviously those that are high functioning.  Right.  Uh, and I really had a lot of success with it and taking them from a firm post-op shoe into, they want to drive and have a little bit of cushion, particularly if  it's a right footed injury. Right. Uh, and, um, and transitioning in that way. So, uh, again, very specific to who I use it with.  And I actually tried to make sure that we're not going to have a lot of coding foo paws and also, uh, you know, you know, balanced billing to patients and things such as that.  Great question.  All right, Dennis, we'll let you wrap it up. I have a little more global, we don't have much time here, so I'll go quick.  Uh, these are just a couple of things that I just wanted to point out to you folks that, that I think some of the physicians could be looking at, and we  don't always think about it on a, on the left side, that that's a, it's actually a new balance shoe.  It's not a bad, I mean, I think I like new balance shoes, but a lot of the souls, the mid soles on the shoes today are, are getting lighter weight.  Some of the shoes they talk about them being so soft and squishy. They're, they're like clouds. Well, yeah, they are.  Uh, they, they, the only way to make that mid soul, which is the EDA, uh, lighter for one thing and softer is to put more air in it. So what happens is it, it compresses.  You've got somebody that supinates or pronates that, that material will compress. And I don't know if you can really see it, but on the picture on the bottom  there, it that's canted off. I think this was, that's a lateral side that this was one of my cavus feet.  And he came in having some real significant problems. Well, part of the problem was the fact that the shoe wasn't keeping him.  He was actually already had, had compressed the side and the picture on the top, you can actually see wrinkles in it.  And if you look at that soul and you, you suspect that set it down and look at it, the patients you're, you say, you think the shoe needs to be repaired.  They'll turn it upside down. Well, it's got a real good, tough outsole on it. It may not even show anywhere, but that EBA may be totally compressed.  And that's part of the problem because the shoe's not giving many kinds of support. And then the other two are just shoe fitting.  Uh, the, the picture in the middle, you can see the guy has the, the heel crash down, and if you look, he's got an ulceration, the doctor's going to do  surgery for his, his great toe, but that's his first metatarsal where you see that ulcer there. His, his great toe is banging up against the end of the shoe.  And then on the other, the blue and souls, I, she was having some toe problems and I made her foot orthoses and she decided to cut the one to fit her, a pair of her shoes.  And if you look at that, look at the toe marks, the toe marks are, are, she doesn't even have the entire toe mark on where she cut it off to go into a shoe.  There are so many people that are misfit. And, you know, this doctor that's doing the surgery on the middle shoe, uh, that guy needs a bigger shoe. Now he's a big guy.  He came in in a 17 size 17 shoe with his mom. And I said that his shoe was too short. She said, well, what do you think we should go?  He probably needs like a 19 or a 20 size shoe, which aren't, aren't real easy to find, but, but part of his problem is he can't get his foot into that shoe  cause it's so crap and small. So, uh, you know, look at shoe fit, but also look at that EVA compression. I think if you start looking at that, you're going to recognize that whether  they're, they're severely pronated or supinated, I know this is very basic stuff, but it's, uh, things that might help you with when you're trying to figure out what's going on.  Thank you.  All right. Well, I want to thank all our panelists. We ran a few minutes over, but I think we're still within the rules.  Um, uh, and so I appreciate everybody's attention and everybody's questions. There's a couple of questions here.  We'll try to answer, uh, uh, type through the system and, uh, thank you all for spending an hour with us this evening.  Uh, thanks to our panelists for taking the time to share their opinions  and, uh, wish you all a good night, Jennifer, I'll let you wrap things up.  Or not, or not. If you look at it, if you look in the chat box, it gives you the link for the, uh, CME, um, if you want to look at that.  Um, she probably had to kick me off the screen sharing now that I realized that. All right.  So here's the information for CME.

Video Summary

On behalf of AOFAS, the 9th webinar of the 2021 Foot and Ankle Focus Series, titled "Game Changers in Footwear, Orthotics, and Bracing," was moderated by Dr. Daniel C. Farber. The panel of certified pedorthists included Denise Genese, Dr. Lance Silverman, Dr. Gary Stewart, and Dr. Michaelis Hogan. The webinar discussed various approaches to foot and ankle conditions, including the use of inserts, orthotics, braces, and specialized footwear. The webinars are provided free to AOFAS members and Orthopedic Residence Fellows with funding from the Orthopedic Foot and Ankle Foundation, supported by grants from Arthrex Inc. and Stryker. Technical instructions were provided, and attendees were encouraged to ask questions through the Q&A tab. The webinar was recorded and will be available for on-demand viewing on the Physician's Resource Center at www.aofas.org. The panelists shared their expertise on topics such as game-changing devices like the Maso for Achilles tendonitis, the Arizona brace for flat foot, the air-heel brace for plantar fasciitis, and the impact of proper shoe and orthotic fittings for different foot conditions. The importance of physical therapy and stretching exercises to complement orthotic treatments was also emphasized. The webinar provided valuable insights and recommendations for managing various foot and ankle conditions with the use of innovative devices and treatments.

Asset Subtitle

Training on footwear, shoe modifications, orthotics, and bracing is limited in most residency and fellowship programs, yet these interventions can make a significant difference in patient satisfaction. In this in-depth discussion, faculty will provide practical tips that you can implement in your practice to benefit your patients.

Moderator: Daniel C. Farber, MD
Faculty: Dennis Janisse, CPed; Lance M. Silverman, MD; Gary W. Stewart, MD; MaCalus Hogan, MD, MBA

At the conclusion of this webinar, you will be able to:

Describe the current trends in OTC shoes, appropriate shoes to recommend to patients, and appropriate modifications
Identify the high-value orthotic interventions that help patient function and pain
Understand the bracing options that work well for various orthopaedic conditions

Webinar from August 11, 2021

Keywords

AOFAS

webinar

Foot and Ankle Focus Series

Game Changers

Orthotics

Bracing

certified pedorthists

foot and ankle conditions

orthotic treatments

innovative devices