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

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

Video Transcription

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 pedorthist Denise Genesey,  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 slash PRC 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. Glad to have everybody here. I wanna especially thank all the panelists. I'm gonna share my screen briefly just to go over how we're gonna 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 Giannisi, 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 gonna 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. We put them in the Q&A box,  and I'll 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 MTP joint, obviously worse with activity.  You know, gets some relief with anti-inflammatories, but he just started a new job at the Amazon warehouse nearby, and 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 at 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?  All right, I'll call Mac out on this one. Mac, what'd you do for this person? So yeah, my approach with this individual is, when individuals say they respond well with insets,  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 started 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 this hollow period that just the patient's experiencing. 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 that I've been talking about.  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 the Morton's extension,  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,  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 heads, 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 Callis 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 on 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 five 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 having them work with an orthodist or pedorthist to do this right is gonna probably have a better result. But a downside of it, I've seen a couple of 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 hyper extension of that IP joint. And they ended up with a new problem  because all the pressure was there when they were walking. So it just, and when you say trim them, that's, 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 some, any dorsal bridging or anything like that, you wanna 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 is building a rocker, theoretically building a rocker sole into the shoe, it's probably gonna be fairly stiff to begin with.  So that is an option as well.  I've told some patients that they could 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. And 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, and in this scenario, it was motion that was the issue. But for some patients, actually motion's not  the pain generator, it's just the prominence over the top of the foot. Right. Sorting out the difference there will help you, you may not need to go to a flex site  just because you see the arthritis on the x-ray. You may need to do something along with the lines of what Lance is suggesting or just having them get a soft up their shoe.  And it's surprising how many people haven't figured that out on their own. Most seem to, but some don't.  Or 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. And in Minnesota, we got nine months of winter and three months of really bad ice fishing. So.  Well, here in Georgia, it's a lot different, okay? And the complete opposite of that. So yeah, and 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 in fashion-wise is important.  Great, any other 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.  Oh, a few more, okay. So let me,  I've been told I need to 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 films there as the worst area of pain. She gets some relief with diclofenac 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 cancel any of these cruises  because she didn't take out travel insurance. So how can we help her? Gary, you wanna attack this first? Sure, you know, initially I would think of, you know, she's going on cruises  and so it's gonna be a little bit warm. So it's telling her to wear a shoe that is wide with a spacious vamp and thick sole. There's not gonna be something she's gonna 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, there's some sandals out there that have this 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 sole 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 liner or here in Georgia, they're going to sit right in there. These shoes are going to sit right in their closet. And so by textbook,  this would be the shoe that you'd want to 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 going to be in Georgia in the summertime and are nine months of heat, it's just going to be really kind of impractical.  The patient is not going to 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 how it's 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 going to 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 going to have something, you know, she's going to 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 logical one is just to skip a couple eyelets.  You just lace underneath the same side, and 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'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. And 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 only other thing I'd 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 longest strengthening or intrinsic foot muscle strengthening can really make a difference for patients that I've found as well.  And then, sir, whoever else wants to ask, 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,  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.  Somebody asked a 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?  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. 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. 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 in 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 going to 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, effective rock if you stiffen it up. If they only have 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 going to create a leg length discrepancy. I think there's a great question  regarding a double rocker for a midfoot arthritis to offload midfoot arthritis. 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, if 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 orthoses, 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  just walked around the office after they put it on and said they no longer have pain. It's  unbelievable, but it just 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 got to have a mid stance there or these  people can't, especially when we get into the older population. There's got to be a mid stance.  They've got to be able to stand. And, you know, you think back, Skechers and some of the other  companies had the rocker soles and they were going to, 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 would, 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 we can approach this with unless 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 does get some, 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, you know, a number of us see. I'm  sure we have a similar patient population in this regard. And when they have, when their arch is  this high, they, you know, it's non CMT. I like to look at this and say, you know, okay, you likely  have a variant of CMT we just don't know about yet, or that no one's ever, you know, they don't  have the genetic testing to confirm that. But this is a patient also with their cavus, you know, 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 dancer's 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 stiffer shoes and ask them how they feel with that. 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, you know, they're  negative for a stress fracture or any other type of, you know, 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 going to 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, more neutral shoe. And they are happy. So yes, 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 going to destroy multiple areas of his foot because he's so out of biomechanics.  And we can do all we want, you know, 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 want to keep, I know we're talking about orthotics here, but we have to have the conversations with the patients too that say, we're going to try to do  this just as a non-surgical management tool, but eventually you're going to 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 it, the people that want to 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,  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 going to 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 on cabus feet,  but I'll do a little ad there, but I, it, I think that we, 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, is the forefoot. You know, you hear, it says it, it didn't fully correct with that Coleman block test. So many of, and, 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, on that forefoot posting. And it's just amazing. Let that I, I literally  in the orthosis, I will make a depression and making all my own stuff. Now I'm not central for having 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 going to 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 going to 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, any forefoot or  hind foot. The heel may not even be in, 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'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,  if you address the forefoot as Dennis is talking about, then you can, you know, pretty fully  correct the hind foot position and that will help them with their overall biomechanical balance. So  you know, 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  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, because of the point that Lance  is making, I mean, you try these non-operative approaches, you hope they go, you know, are doing  okay for a while, but you know, their, their, their biomechanics of their ankle and their foot  motion is just not normal for them. And, and this, you know, 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 the 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 legs 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, like Alice said, that's a great idea. That's great. I think I think one of the  awesome 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. I, if I have a patient with this issue, I, even if I write the orthotic, I actually have them have a follow-up, a follow-up visit with the orthotic, because  Dennis, I wish I could just transport you or somehow have you fill our, 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,  a 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 lab,  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, you know, 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 going to 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, you know, 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 going  to be counterproductive for this patient. I mean, we don't want a high heel, but you've got to 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. I mean, I think some of the companies, they just want to 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 going to 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, you know, 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 got to 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 superfeed  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 want to?  Yeah, I mean, so I keep picking on you. I feel like I just keep picking on you. It's probably because my photos is right under yours, at least on the screen.  I don't mind. At least it's all good. So, you know, we all see this patient, you know,  commonly, you know, 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, 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  is like a blue or maroon. I should have sent a picture, and the cost is not prohibitive.  And then I'll do different things with posting in different areas. A medial posting to really try to open up that sinus tarsae, 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 if they've already failed an 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 would 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. There's no night splint that individuals want  to 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 because I've tried to wear one a couple times, and doctors are the worst patients,  and I had to just resort to wearing a wig 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 Sig Hansen's kind of  concepts here, We got an underactive peroneus longus and strengthening that, strengthening some intrinsic  foot muscles, teaching people those things can give people a lot of foot comfort,  you know, and help them prevent further collapse.  We talked about some of the basics. I just put on here some longitudinal metatarsal arch support, scaphoid pad, things like that. Simple things that you can kind of  get people at least started with something for, you know, as a trial.  I'd ask folks, what's your role for custom orthotics in this setting?  Yeah, I mean, here, I like, 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 taped to the bottom of the foot. So  you get a nice heel cup and if you can control the heel, you've got a little bit more of a chance of  controlling the rest of the foot. For some of those more severe, yeah, something here,  I like a nice high heel cup, but it's hard to see on that picture of mine. And that will really  help control the heel. That's a good place to start. And with some of those feet, it's sort  of an old-fashioned way. And again, you commented on the orthotics and the custom orthotics.  So much of what we do today is 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 forefoot wedge. And that actually, those two put together  actually really help to bring that arch up and take some of that stress off that posterior tendon.  So we have a question about, for medial high foot pain along the posterior tib, if you use arch support or an ASO or a combination, one or the other or both?  I'm very transparent with this. Based on their demand and 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 both a non-custom support and  say, hey, an ASO. 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. That may work for  them and really strap it up tight. And also that gives them a little bit of play based on what  shoes they may have at home at the time prior to me taking a step to a custom brace. But again, no specific science to that, but I believe patients will be able to use both of those  but I believe patients, and you educate them and speak with them, they actually enjoy having some  choices and options around how they manage their disease state and their problem versus rigid, fixed, et cetera, and this is going to be it. So that's the approach I take.  So the OIP answer for this sort of thing is often a modified UCBL. Thoughts on this device?  Yeah, I mean, you know, this is the one when I was training with Wynn in Philly, you know, this is her article and we would always talk about it. And I first came out  and practiced and started trying to use it and goodness gracious, I mean, people did not, they just didn't like it. I mean, it may work for that particular study in the paper.  And so, but I think that I do use, it's mentioned in one of the Q&A, there is a particular PTTD  strap brace that is a little bit more specific than the ASO, that is much more comfortable than  the OITE question answer, although that is effective. And so I tend not to write these because it is relatively expensive and I give them kind of that cough brace that will provide  some support. And we realize, and I'm clear when we get them the cough brace, 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. And so I will do that. I'm a big believer that  some mobilization, rest, physical therapy, and some anti-inflammatories will help with kind of  a simple issue of 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 sensate, not the insensate ones,  but are sensate. The insensate ones, unless I really trust the orthotist that they're getting  it from, I'm very careful. I don't want to have them get an ulceration, but you have to know what  it's capable. And it's the really heavy, big people. 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 agree to do it in lieu of surgery  or with failed surgeries when they just do not want to go back under the knife again and don't  think anything's going to work. I mean, this is still in my wheelhouse. I mean, I, this, or  sometimes even a Ritchie brace, but a Ritchie type brace, but I use it for the same patients  as Lance mentioned. 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 right, 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 bonding with them. And this brace and the series of braces are in the handout I give them. So they know it's on  the spectrum. And then and some individuals, as Lance said, they really do not want surgery.  And if you have an orthotist that you work closely with, I trust our team 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 some of the complex Hanford surgery we do for this can really be 12 to 18 months.  So and that also gives them information on therapy and Alvarez protocol, et cetera. So  it is still in my wheelhouse. I can be archaic in that regard, but some patients take it and love  it. Others will throw it at you when they come back in 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. You're right.  And you can have a lot of variations of this as well. I mean, this was the basic Arizona. This  was, this was the original, but you can get this brace with an articulated ankle and maybe you  don't have to lock up that ankle. You want to control it, but you don't necessarily have to  mobilize it. So you can get an articulated Arizona brace or Arizona type brace gauntlet. And then there are some, some short versions of this more like an SMO, but if you go to the  shorter version, even using it in place of the UCBL, if you go to that, you can have a softer  plastic. It's not as bulky 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, it work with your practitioners. 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. If it's  on their right foot and they're driving it's hard to drive with this because you can, you're used  to using your foot to drive. So they've got to use their leg to drive. The articulated may be  fine. You may be able to let them use their ankle some. And so it 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. 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  early ankle arthritis. You know, she's got some relief. 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. 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 and, and that can be also helpful to take some of the  stress off the ankle. Any specific things that the panel would do. And then I wanted to go on  to our, our round table of 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 up to the middle of the leg. If trying to get like 25% or more of that  body weight to transfer if possible, patellar tendon bearing orthoses. If you have somebody  who's super dedicated to avoiding surgery here, you can do PTBs kind of thing. That's even more  takes a lot of talent and the orthotists 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 going to go around the horn. I'll start with myself and then I'll just pop everyone up and you  can give a couple of minutes commentary on some things that really 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  of orthoses. So so, so mine is a Maso for Achilles tendonitis. And this is something I learned when I  moved here to Penn. And so I have to credit Keith Watner and Wen Chao and probably Paul Heck before  them or with them, maybe with this idea. So it's not my own, but this is something that for patients  to come in with kind of long standing or moderate standing Achilles tendonitis. And normally you'd  put them in a can booth. That's what I was always taught. And this device is really helpful. It's  in the, it's in a little bit of a Aquinas or take some tension off there. It's got a blowout along  the back of the Achilles so that they don't get pressure on the tendon. And it's a great way to  more functionally immobilize them. They could wear it with a shoe. They can hide it under a  pair of pants and they can use it throughout their rehab process. So this has been something  that sounds super helpful in, in settling down a lot of patients with Achilles tendonitis and  patients are pretty accepting of this for the, for the most part. So I'm going to go to Lance  with big stuff here. The IDEO brace. So I had a really awesome experience down at the center for  the intrepid and the army hospital down there several, more than a decade ago, and was introduced  to this brace that they were using to, instead of amputations to do limb salvage in these mangled  lower extremities or people with severe post-traumatic arthritis. And since then I've attempted to get patients to get these. It's been definitely possible with work comp and, and,  and a third party injury claims, personal injury claims. And insurances are starting to allow  versions of these. They're expensive because the materials are carbon fiber and it's very expensive  and technically challenging thing to make. But the orthotists love to do it. And I've seen  the athletic thin male up to many, 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, 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. But, you know, when I have a patient and I'm able to,  you know, get them this proper orthotic in with the proper shoe combination, something that doesn't  have a high arch or something that's not too thin, the patients just love it. I mean, they kind of  just come in and say, well, thank you if it was that simple. And it's not for those big cavus  deformities that we showed earlier, but something, again, a little bit more subtle. And 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, you can really give someone some help. And here you have  more of a kind of plastic kind of 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 give them something  that's going to be durable as well. And so in my practice, 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, Mack, you chose the Air Heel Braid. Yeah, I mean, this is, you know, some of  you have likely seen this. It's an off-the-shelf product. You know, our, the company we contract  for DME and our offices, they carry this. It is, you know, a billable brace with insurance  for certain diagnoses, particularly Achilles tendonitis, plantar fasciitis. 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, along the Achilles, if they have mid-substance  Achilles tendonitis, it can be helpful, but also to offer a number of things in the foot.  Plantar fasciitis, heel pad syndrome, it's not directly under the heel, but when they walk in  the glide, I found it to be helpful. And I've even used this to offload an individual who doesn't  want to stay in a boot and they're transitioning from, you know, fifth metatarsal avulsion fracture  or something that quite frankly is not limiting them enough to put them in a cam boot. And this  is a great transition device. And so I got to keep it in my wheelhouse to help for a number  of different pathologies and have had good fortune with it. Are you finding that if 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 year period of giving them a boot? Yeah, so it's a great question.  And I ask these types of questions of our vendor for DME, and it has not presented an issue in  regards to how they've coded and built for it. Now, again, some of these individuals, I would  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? And I've 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? And transitioning  in that way. So 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 balanced billing to patients and things  such as that. Great question. All right, Dennis, we'll let you wrap it up. You have a little more  global. We don't have much time here, so I'll go quick. These are just a couple of things that I  just wanted to point out to you folks that I think some of the physicians could be looking at, and we don't always think about it. On the left side, it's actually a new balanced  shoe. It's not a bad, I mean, I think I like new balanced shoes, but a lot of the soles, the mid  soles on the shoes today are getting lighter weight. Some of the shoes they talk about being  so soft and squishy, they're like clouds. Well, yeah, they are. The only way to make that mid sole,  which is the EVA lighter, for one thing, and softer is to put more air in it. So what happens is it compresses. You've got somebody that supinates or pronates, that material will  compress, and I don't know if you can really see it, but on the picture on the bottom there, that's canted off. I think that's the lateral side. 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 straight. He was actually already had compressed the side,  and the picture on the top, you can actually see wrinkles in it. And if you look at that sole,  and you suspect that, set it down and look at it. The patients, you'd 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 EVA may be totally compressed, and that's part of the problem  because the shoe's not giving him any kind of support. And then the other two are just shoe  fitting. The picture in the middle, you can see the guy has the heel crashed down, and if you look,  he's got an ulceration. The doctor's going to do surgery for his great toe, but that's his first  metatarsal where you see that ulcer there. His great toe is banging up against the end of the  shoe. And then on the other, the blue insoles, she was having some toe problems, and I made her  foot orthoses, and she decided to cut the one to fit a pair of her shoes. And if you look at that,  look at the toe marks. The toe marks 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, that guy needs a bigger shoe. Now, he's a big  guy. He came in in a 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 real easy to find. But part of his problem is he can't get his foot into that  shoe, because it's so crap and small. So, 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 severely pronated or supinated. I know this is very basic stuff, but it's  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. I appreciate everybody's attention and everybody's questions. There's a couple of questions here we'll try to type through the system. Thank you all for spending  an hour with us this evening. Thanks to our panelists for taking the time to share their opinions and wish you all a good night. Jennifer, I'll let you wrap things up.  Or not. Or not. If you look in the chat box, it gives you the link for the CME. If you want to  look at that. She probably had to kick me off the screen sharing now that I realize that. All right. So here's the information for CME.

Video Summary

Thank you all for joining us tonight. I hope you found the discussion on game changers in footwear, orthotics, and bracing informative. We explored various approaches to managing foot and ankle conditions, including using different types of orthotics, braces, and footwear. Our panelists shared their insights and experiences, offering suggestions and considerations for each scenario. We discussed the importance of proper shoe fit, the use of night splints, and the potential benefits of different orthotic devices, such as the Arizona brace, Masal brace, and Air Heal brace. Physical therapy and stretching exercises were also highlighted as potential adjuncts to orthotic treatment. Each patient case was approached with a focus on individualized care and finding the most appropriate and effective solution. We encourage you to consider the patient's specific needs, preferences, and activity level when selecting the most suitable treatment options. Remember to consult the full video or transcript for more detailed information on each case and to access the full biographies of the panelists. Thank you for joining us and have a great day.

Asset Subtitle

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

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.

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

Keywords

game changers

footwear

orthotics

bracing

managing foot and ankle conditions

orthotic devices

Arizona brace

Masal brace

Air Heal brace

physical therapy