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In the February 25th 2012 PMNEWS, vol # 4,394 a podiatrist writes in to basically say that orthotics are a waste of time and that podiatrists only deal with orthtotics because of a financial gain. I'll copy the post with the doctors name removed, followed by my response.

What's your thoughts on this topic??

-------------------------------

RE: Do Runners Need Orthotics? (Kevin Kirby, DPM)
From:  , DPM

In response to Dr. Kirby's query, I feel running shoe selection is more important than custom orthotics. Most shoes have intrinsic built-in characteristics for runners and their environments. I have found the orthotic that comes with the shoe or an OTC has been satisfactory in the majority of the cases. Although a small percentage may benefit from a so-called "custom" support, I believe the primary motive for prescribing is financial. In all honesty, if you took the profit motive away from "custom orthtotics", many podiatrists wouldn't go through all the trouble attendant with them.

 --------------------------------

FROM: H. David Gottlieb, DPM
             Baltimore, MD
RE: "Custom Orthotics"

Dr. B, why the use of quotes around custom orthoics in your recent post regarding runners?

An insert is either custom or it's not. If the prescription for the orthotic is marked "Post To Cast" then I agree that it's not really a functional orthotic under anyones methodology.

As to your statement "if you took the profit motive away from "custom orthtotics", many podiatrists wouldn't go through all the trouble attendant with them" I find that there is very little trouble attendant with prescribing and dispensing orthotics because they work well for the majority of my patients. And as a VA employee I have no profit motive. My incentive is to fix my patients problems so I can see other pateints. I evaluate my patients well, write a customized prescribtion for each, and explain how they should use them. Some orthotics may need an adjustment, but the overwhelming number do very well. And because they work for me I use them alot.

Other podiatrists here don't get good results with orthotics and therefore don't believe in them. They don't use orthotics or they have me do it. I tell our residents and visiting students that if orthotics take up too much time they are not doing it right. They need to figure out how to do othotics correctly or don't do them at all.

H. David Gottlieb, DPM

Do you use orthotics mainly because they work or because you make money from them?
They work.
75%
(9 votes)
Financial gain.
25%
(3 votes)
Equal amount they work and financial gain.
0%
(0 votes)
  • Comments (17)
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  • For 23 years of practice, I can confidently opine that there is no profit motive in custom foot orthoses.  Why? Because they work as advertised when properly prescribed and made and they last for years.  Patients who are compliant with their orthotics typically do not return for treatment of relapse or recurrence of their mechanically caused problems, depriving us of billable services.  They are good medicine, plain and simple, despite the paucity of research "evidence" on which to base their use.

  • Four years have past and there is no new high level peer reviewed evidence proving custom made subtalar neutral cast (Rootian) foot orthotics are useful.

    Sad.

    In fact there is a 2017 peer reviewed article:

    Challenging the foundations of the clinical model of foot function: further evidence that the root model assessments fail to appropriately classify foot function

    • Hannah L. Jarvis,
    • Christopher J. Nester,
    • Peter D. Bowden and
    • Richard K. Jones
    Journal of Foot and Ankle Research201710:7
     
    that concludes that subtalar joint cast, Rootian based custom foot orthotics as a clinical treatment should not be practiced by professionals!!
     
    Sad.
     
    Dennis
     
  • The word podiatric means the foot. I believe that any non podiatrist can perform foot biomechanics which

    I believe is the same as podiatric biomechanics. I do not know any difference between the word

    foot and podiatric.

    foot biomechanics concerning theLamina pedis concept existed in the literature but i do noever remember such a concepts

    being taught in school For example the lamina pedis concept regarding as the calcaneous is everted the foot is more rigid.

    Please read the text by Sarrafian functional anatomy. Just think of all the cadeveric studies performed by

    orthopedists. Were podiatrists taught that the foot becomes a mobile adaptor to the ground as the calcaneous

    everts, well this is what I was taught.  How can I look a patient in the eye and tell them that orthotics

    are needed to control abnormal pronation ( the calcaneous is everting during the gait cycle when "normally it should be resuponating) ? How do I tell a patient the foot bones are loose and the calcaneous is not 

    resuponating at the right point in the gait cycle and the orthotic will control such abnormal pronation or eversion

    of the calcaneous. How can I say this when the lamina pedis concept exists in the literature and has it ever been disproved. Yes there are may theories created some by podiatrists and other specialties as well.

    Perhsps the schools are teaching what these other concepts are and what cadaveric studies have been done.

    To say that podiatrists are the only ones who are specialists in foot function I believe cannot be done when other specialists are publishing articles with different foot biomechanical theories.

    Please forgive me for doing so but there are many podiatrists out there that I believe know more than I do

    regarding this at STJ orthotics labs. Also I really enjoyed reading articles I believe his last name was Dr Kirby

    Also there is a wonderful podiatrist out there that made a patent regarding foot orthotics.

    Podiatrists are experts but I feel we are not alone.

     

    dan

     

    class 84

  • Dan:

    You state,  "The service of podiatric biomechanics is being performed by the podiatrist or possibly even the pedorthist or other licensed practitioner that reads about podiatric or any other specialist type of biomechanics that was not taught to me in podiatric medical colleges."

    I thought that podiatric biomechanics is part of the standard curriculum in our schools?  Please explain.

    Ed

  • Orthotics are a component service of podiatric biomechanics.  A service, not just a device. Chronic repetitive strain to structures of the foot caused by occupational, avocational and pathomechanical issues is the cause of a large percentage of the foot problems we see and podiatric physicians are uniquely qualified by training to address such issues.

    We provide thorough and comprehensive biomechanical evaluations and utilize a number of tools to make benefiical changes in pathomechanics in order to achieve the desired therapeutic effect. That may be done via changes in shoegear, gait training, therapeutic exercise and mechanical devices such as night splints, AFOs and foot orthotics.

    The provisioning of prescription foot orthotics involves a biomechanical exam required to create the proper prescription, casting techniques which may vary with patient pathology (we do not use the same technique for all patients and the doctor must perform the casting), dispensation and fitting of such devices, evaluation of the biomechanical effects of the device and regular modification of such devices based on patient response and observed/measurable gait changes.

    We must not only maintain high standards in the practice of podiatric biomechanics but endeavor to educate patients of the nature of this service.  Patients are not recieving such a service from a DME supplier.

     Dear Eddie Davis DPM,

     

                I respectfully have a different opinion. My opinion coincides with DME coding.

    An orthotic is just a device from a DME code that is billed for . The service of podiatric biomechanics is being performed by the podiatrist or possibly even the pedorthist or other licensed practitioner that reads about

    podiatric or any other specialist type of biomechanics that was not taught to me in podiatric

    medical colleges. The orthopedic literature is full of different foot biomechanical theories. After a

    biomechanical exam the prescription provided can instruct the pedorthist on how to cast and which position if needed. Problem is even if a perfect cast is taken it is up to the laboratory to modify the cast.

    That DME provider who is contracted with the insurance company can follow the explicit instructions of

    a podiatrist or other licensed prescriber. The patient is happy because it was covered by the plan and

    a biomechanical exam was performed. Please understand the time it takes to perform a biomechanical exam for foot pain is probably covered within the insurance plan by a participating practitioner and there is

    no need to charge patients for covered services. In the event the orthotics don't work the patient does not

    have to worry about losing money. As a podiatrist isn't it most important to help patients by educating them

    that in network orthotic care by a DME can be provided by a contracted DME provider and the patient

    has the choice also to spend money out of network with the possibility that the orthotics will not work and that such money spent may be lost?

     

    Daniel

     

    class 84

     

      

  • Eddie - I always knew I liked that Sam Adams. In fact, I drank 2 when I was out last night.

  • Orthotics are a component service of podiatric biomechanics.  A service, not just a device. Chronic repetitive strain to structures of the foot caused by occupational, avocational and pathomechanical issues is the cause of a large percentage of the foot problems we see and podiatric physicians are uniquely qualified by training to address such issues.

    We provide thorough and comprehensive biomechanical evaluations and utilize a number of tools to make benefiical changes in pathomechanics in order to achieve the desired therapeutic effect. That may be done via changes in shoegear, gait training, therapeutic exercise and mechanical devices such as night splints, AFOs and foot orthotics.

    The provisioning of prescription foot orthotics involves a biomechanical exam required to create the proper prescription, casting techniques which may vary with patient pathology (we do not use the same technique for all patients and the doctor must perform the casting), dispensation and fitting of such devices, evaluation of the biomechanical effects of the device and regular modification of such devices based on patient response and observed/measurable gait changes.

    We must not only maintain high standards in the practice of podiatric biomechanics but endeavor to educate patients of the nature of this service.  Patients are not recieving such a service from a DME supplier.

     

     

    "If ye love wealth better than liberty, the tranquility of servitude
    better than the animating contest of freedom, go home from us in peace.
    We ask not your counsels or your arms.
    Crouch down and lick the hands which feed you.
    May your chains set lightly upon you,
    and may posterity forget that you were our countrymen." Sam Adams

     

     

     

     

     

  • Dan--

     

    Everybody is happy in your scenario except the podiatrist, who did all the precribing, ordering, and was the front man for the responsibility for treating/pleasing the patient, and got zero in return.  That's under the best of circumstances. If the patient isn't pleased in any way--rightly or wrongly--the poditarist takes the hit.  A lot of time and effort spent--a lose/lose proposition.

  •  

    Hypothetical situation about a possible situation:

    The whole key is if a patient is part of an insurance plan that contracts with a non podiatrist DME

    provider then the podiatrist does not expect to make a profit off the sale of the device.

    Selling a device may not be a so called "physician service". Also the podiatrist can explain to the

    DME provider how to fill the RX and let the patient know it will be in network and probably cheaper for them

    to use the DME provider. The podiatrist is happy because he helped the patient and the patient is

    happy because it was cheaper for them. The podiatrist can also explain that if the patient chooses to

    use them to make the orthotic as an out of network benefit it may be more expensive and the orthotics may

    possibly not work and the patient will possibly end up losing money.

    Any opinions as to the above situation?

     

    Daniel

     

     

  • The poster's comment is really silly as we expect to make a profit from all services we provide; it is part of capitalism.  Certainly, as professionals, we endeavor to provide services which help our patients, with the profit motive being secondary.

    Overuse of surgical treatment, in my opinion, has been more problematic in all of medicine.

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