The are 2 types of podiatrist in this world. If somebody ask you Do you over prescribe or under prescribe? What would be your answer?

In the world of orthotics at university and at biomechanics courses we are taught, If your patient has this injury you do this orthotic modification. Ie. if a person has a neuroma you put on a met dome. If a person has a painful hallux limitus you put on a  morton’s extension. This way of prescribing is perfect in a textbook, but doesn’t always work in reality. Choosing what the most appropriate and perfect prescription is, for each client is a hard task.

At an orthotics lab you see a mix of everything. What some people create is a masterpiece of orthotic textbook prescription. High arches with quarter posts, met domes with forefoot extension and cuboid notches topped off with a cluffy wedge. At this point you say ‘wow, this person must know their stuff”. Only then to learn that the podiatrist wanted to fit the orthotic intos a dress shoe and that it was the first orthotics that patient ever had. Reality is that this patient will probably put that orthotic in the bin and ner use it. It wouldn’t fit into their shoes and was uncomfortable.

 

When should I under prescribed?

In my eyes this should be most of the time, and here’s a few reasons why.

  1. You can fit simple orthotics into shoes better. The more shoes your client can fit them into the more compliant they will be with wearing them.
  2. Think of it like a drug. A client has hypertension and goes to the doctor. He never had any drugs before. So the doctor prescribes something for him. At this point the GP is never going to put that person on the highest dose and a mixture of drugs. (this might be ideal in a text book for treating it). Reality is though, that every person will react differently to different drugs. The doctor needs to keep in mind what side effects will the drug cause, which drug is causing the side effects and at what does do the side effects occur. Due to these reasons the doctor is likely to start the person of with a minimal dose, that he thinks will help, and a drug that most people tolerate. Now….  swap the word drug to orthotic, hypertension to a foot pathology and dose to how complicated the orthotic prescription is.
  3. Comfort. To anybody that is new to orthotics, putting something under your will feel weird and take time to get used to. never mind adding on domes and wedges. The more simple the orthotic, the quicker they will get used to it and more comfortable they will be.
  4. Put them in a more supportive shoe, so the orthotics can be less supportive.
  5. Don’t rule out how powerful general arch support can be. Not only does it help offload the forefoot a lot, but also has a big influence on the line of gait.
  6. You only need the minimal amount todo the perfect job. ie. if a runner can train 3x a week and win. Why would he train 6x per week risking injury, and over training.
  7. Save money. The simpler the orthotics the cheaper they will be for you. Just ask yourself. Will adding this to the orthotics really affect the outcome?
  8. Less bad reviews. 20% of something is better than 100% of nothing. Make your orthotics too complicated and your client won’t wear them. They may have more pain and discomfort which means more chance of them not coming back, leaving bad reviews or  have more reviews and remakes. If the clients 20% better they will be happy. and from there you can improve on it.
  9. It’s easier to add than take away.
  10. It saves time. During your assessment ask yourself. What tests really make a difference to your orthotic prescription? Are measuring angles really necessary? Simple answer is no. You don’t want to prescribe 100% to those measurements. Keep it simple.

When do I over prescribed?

  1. When the patient wants you too. If a client has previously had orthotics and says they want more support, then yes, no problem.
  2. When an injury still wont shift. Then yes add more to the orthotic. (if they shoe has enough room)
  3. If they have a major issue that needs major treatment. I.e a motorcycle crash when the foot has had multiple surgeries.
  4. A high risk client – RA, ulceration, deformity. Areas that need emergency or high power offloading

Can you ever do the perfect orthotic? Right in the middle?

The question is. what is the definition of the perfect orthotic prescription?

  1. One that the client wears
  2. Fits into their  shoes
  3. Helps resolve the pathology treated? It may not always resolve 100%.  If that patient doesn’t follow the plan and wear good shoes. But again 20% better is better that nothing, Don’t blame yourself if this happens it’s not your fault. You still helped them!
  4. If their happy with their last set, don’t change the new sets prescription.

 

So the next time your prescribing just ask yourself these 3 simple questions. Will this extra bit make a difference to the outcome? Will it be comfortable for them?  Can it fit into their shoes? Will they be compliant?

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