Insights On The Evolving Nature Of Orthotic Education And Casting
June 2014
Acknowledging changes in the way podiatry students learn orthotic therapy, these experts discuss how such changes affect the quality of casting, and how young practitioners can gain casting experience. They also discuss common questions from prescribing podiatrists and debate the value of over-ground weightbearing scanners.
As a result, fewer and fewer practitioners can explain Root casting theory, how it developed and how it facilitates normal foot function, according to Dr. Phillips. He says some practitioners have adopted the idea that DPMs are creating an arch support, a model of what the foot is supposed to look like, and if one props the orthotic into this position for a while, after removing the prop, the foot will continue to look the same.
“The decline in teaching foot orthotic/biomechanical theory in both the classroom and clinic has degraded not only the quality of the casts but also the understanding and expectations of the practitioner,” claims Christopher Smith, DPM.
Since many practitioners lack experience with negative casting, Dr. Smith feels they may simply defer the casting procedures to office assistants or CPeds. He says this reflects a “gross indifference” to casting, which he says requires both art and science.
“At best, this is simple dilution of knowledge and skill, somewhat motivated by office economics but more importantly, it reflects a failure of the profession at large to appreciate the significance of a good cast of the foot,” asserts Dr. Smith.
Paul Scherer, DPM, has not seen a decline in quality negative casts or scans at ProLab Orthotics but notes his orthotic lab only accepts non-weightbearing plaster or fiberglass casts or scans that capture the posterior surface of the calcaneus and a forefoot to rearfoot relationship. However, he does note seeing a large increase in new clients, particularly from the East Coast, who want to send crush boxes for functional orthotics, which the company declines.
“It is obvious that these practitioners do not understand the concept of how orthotics are intended to prevent subtalar or midtarsal joint compensation to decrease tissue stress,” says Dr. Scherer. “I believe their instructors or orthotic manufacturers may have told them that a proper functional device can be made from an impression of the foot in a pathologic position. I do not believe this is possible.”
In exhibit halls, Dr. Scherer has heard manufacturers telling practitioners that a lab can make a proper three-dimensional functional device from a two-dimensional pressure mat or scan. He says this idea is just as much an illusion as the technique of touching the full plantar aspect of a foot to the glass plate of a foot scanner. He feels it’s not the schools that are teaching this concept but rather that practitioners have succumbed to “the nonsense perpetrated by financial opportunists and amateurs who work outside of academia.”
Dr. Phillips acknowledges a rise in the number of individuals who are determined to return to the pre-Root era of arch supports. He says this leaves young professionals confused by a number of competing theories on biomechanics and teachers (especially at the post-graduate level) who do not want to be bothered trying to sort out fact from fiction.
“I believe the problem goes much deeper into the profession, though, and underscores many problems that continue to haunt the entire gamut of biomechanical knowledge and practice,” says Dr. Phillips. Those problems include:
A change at the entrance level of podiatry school by discarding the podiatry school admission test and adopting the MCAT. While Dr. Phillips says this certainly makes sense in terms of making it easier for medical college applicants to also apply to podiatry schools, it has the disadvantage of sending a message to applicants that they do not have to have basic 3D visualization skills, which are of paramount importance in understanding biomechanics.
The struggle for podiatry to become recognized as a true medical specialty has increased the number of hours spent in general medical studies, often at the expense of biomechanics training. Despite this, Dr. Phillips notes the schools still continue to train students in surgery as if new graduates are going to practice surgery before entering residency training. Residency interviews concentrate on how many bunion surgeries the prospective resident already knows, not on the mechanisms that lead to bunions, which he calls “totally backward.” He argues that the standard pat answer that bunions form because of first ray hypermobility “is at best a very superficial answer.”
Dr. Phillips notes that applicants for residency programs are required to discuss flatfoot surgeries without any idea of all the various types of flat feet, which flat feet are normal and which are abnormal, and how to examine an excessively pronated foot. In addition, he says applicants for residency programs must enumerate a number of joint destruction surgeries without any discussion of what changes to expect after surgery on the function of the foot and other parts of the body. Even with the upgraded CPME 320 residency requirements, Dr. Phillips says the minimum activity volume for the number of surgeries is more than five times the number of biomechanical examinations, which he calls “exactly the reverse of the real practice of podiatry.”
Failure of schools to actively recruit the brightest biomechanical minds for teaching. Dr. Phillips acknowledges that there are “extremely dedicated people” teaching biomechanics at the schools but there are far too few of them. He says few if any funds are dedicated to biomechanics research at the schools and faculty are not well rewarded for producing strong biomechanics research.
The publication in recent years of a number of biomechanics research papers that claim to discredit Root biomechanical theory. Dr. Phillips says although such papers surface in reputable journals, podiatrists rarely write them. Recently, he personally contacted a number of authors of orthotic efficacy papers regarding the reasons they selected their particular orthotic materials for research.
“I shouldn’t have been too surprised to find that none had any idea about the properties of the materials they chose,” says Dr. Phillips of the study authors. “As a result, in almost all research, all orthotics are considered to be equivalent, regardless of foot type, orthotic casting technique or orthotic shape, orthotic prescription variables and orthotic materials. With equivalency of all orthotics, then, straw man arguments are set up as to whether Root theory is correct or incorrect.”
Failure to further research and teach midtarsal joint function. Although the orthotic cast’s most important function is capturing the forefoot to rearfoot relationship, Dr. Phillips says physicians spend little time researching and teaching how that relationship changes when the subtalar joint pronates and supinates. He says the profession continues to teach only to the level of understanding that the foot is either a mobile adapter or a rigid lever. Yet if one asks any student what type of lever the foot is, he says almost none can tell you whether it is a class 1, 2 or 3 lever.
Furthermore, Dr. Phillips notes if one asks students to explain how any surgery changes the leverage effects of the foot, “you will get a blank stare.” He notes a few instructors have tried to introduce to the profession the clinical identification of the subtalar joint axis, an identification that he totally supports. “Yet even these brilliant minds are focusing on the foot as if the foot were a solid block of wood between the subtalar and the metatarsophalangeal joints,” says Dr. Phillips.
Dr. Smith says the skills to cast a foot with the subtalar joint neutral and the midtarsal joint locked are difficult because this procedure is both a science and an art that requires skilled professional guidance. With practice, he notes one can obtain positional skills but maintaining that alignment while the plaster cures is an additional challenge. As the practitioner fatigues, the foot drifts into a supinated position, which he believes is the most significant cause of orthotic discomfort and failure.
However, Dr. Smith notes the new digitizers and scanners “offer a great hope” for that problem because maintaining proper foot position/alignment requires minimal time, ranging from an instantaneous flash to an approximately 15-second scan.
There is minimal formal post-graduate biomechanical learning because very few seminars include appropriate lectures, even at state seminars officially sanctioned by the American Podiatric Medical Association, according to Dr. Smith.
Dr. Phillips notes his alma mater was able to only do so much in regard to biomechanics education. He says the dedication of the aforementioned orthotic laboratory improved the orthotic prescribing practices of those in the profession. Although the Prescription Foot Orthotic Laboratory Association (PFOLA) was supposed to bring the same dedication to the entire profession, he notes this has failed to materialize in the last few years. Part of the problem, says Dr. Phillips, is that it is difficult to learn biomechanical principles and practices in large lecture halls. He suggests that podiatrists can best learn this in small groups.
Dr. Phillips also cites the influence of his father, a podiatrist who was interested in biomechanics, and who noted that it was not unusual for practitioners who wanted to learn biomechanics to visit and work with other practitioners who were considered more expert in this arena. If he were a young doctor today, he would contact known experts who are seeing 10 or more orthotic patients per day, and watch and assist in their offices. Although there is no CPT code to bill for such time and many people may not want to teach because they may feel slowed down, Dr. Phillips argues this is the only model that seems to have worked well in the past.
Q:
Has the decline in the formal teaching of foot orthotic therapy at schools of podiatric medicine affected the quality of casts and prescriptions submitted to labs?
A:
Noting that while he does not own a laboratory or have financial connections with any laboratory, Robert D. Phillips, DPM, says he does notice that young practitioners have little idea of casting theory. As he says, the only textbook to deal with orthotic casting has been out of print for many years.
Q:
How can young practitioners who lack skills in casting and prescribing custom foot orthoses obtain further knowledge and training?
A:
As Dr. Phillips recalls, he had a great difficulty in learning orthotic casting instruction when he was a student. When a group of students from his graduating class of 1979 felt frustrated that they weren’t learning casting well, he recalls making an appointment with Merton Root, DPM, where they spent four hours with the master caster himself, learning his technique. He specifically remembers spending half the time learning to position the patient properly, saying without proper patient positioning and the proper physician posture, it would be impossible to make a good cast. After graduation and taking specific biomechanics clinics in which he built the orthotics himself, Dr. Phillips recalls having much to learn. In those days, he notes a great many practitioners still made their own orthotics in their offices or in little laboratories they built in their garages. “I want to say that if you really want to learn orthotic practice concepts, do your own casting and build the orthotics yourself,” says Dr. Phillips. “By doing so, you really do find what works and what does not. I have had few, if any, patients refuse to wear orthotics because they were not perfectly polished. In fact, when I was in private practice, I could tell if a person was wearing his or her orthotics by how well his or her socks were polishing the plastic.” Dr. Phillips recalls using the Root Lab for a few orthotics and says Dr. Root would do an annual seminar free of charge for anyone who used his laboratory. These seminars never offered any CME credits but he says they were invaluable in learning what was working for others as well. “It was truly one-on-one teaching that is almost impossible to find anywhere today,” he says. “I have been the beneficiary of a person who built a small orthotic lab dedicated mostly to making the profession better and only secondarily to making a profit.”