The Issue of Biomechanics, Orthotics, and "Qualified Practitioners"

The recent comment from Denise is the impetus for this post, so thanks to you, Denise!

The art and science of foot and gait biomechanics is a still-developing field, in many respects. And there are many practitioners, both orthopedic and podiatric, who have had some training in biomechanics. But this is no different than saying most have had some training in surgical techniques - of course they have - it was one of their medical training requirements. But at some point in their training, every doctor, regardless of their license, decided to focus on one or maybe two areas of practice. While a surgeon needs to understand biomechanics to guide his or her surgical interventions, does not make that surgeon a specialist in biomechanics as it applies to assessment for and casting for foot orthotics.

Likewise with an understanding and expertise in the casting for, and the manufacturing of, orthotic devices. Again, there are varying levels of expertise. This is an important distinction, because many people go see a podiatrist or orthopedist who suggest orthotics, and while they are qualified to make such a suggestion, and even understand how such devices should function, they themselves may not be the best person to do the proper gait analysis, do the correct casting techniques, and use a laboratory that is well- versed in all the nuances of particular pathomechanics to inform their making your orthotic devices. Or, you wouldn't hire a plumber to put in a new light switch. Both the plumber and the electrician are contractors, but they have specialized skills.

Biomechanics is still a somewhat "fuzzy" science, in that there are some competing theories by podiatrist vs. orthopedists. These competing theories are somewhat driven by turf wars - orthopedists tend to look down at podiatrists, and podiatrists may justifiably resent having aspersions cast their way. But as the client, you need to do your own investigation, not as to the operating theory, but as to the level of training your chosen practitioner has received, how long they have been practicing, and their success with other patients having the same issue as yourself. Do not hesitate to ask the doctor to put you in touch with such patients, to ask their experience with outcomes.

Not all casting techniques are created equal, as well. Weight-bearing casting takes a substantially different "picture" of the foot than non-weight-bearing, neutrally positioned casting. The proper technique will determine whether your devices actually work, or just maintain your feet in their worst possible position. Think of when you, as an infant, had your feet casted for your talipes. If the foot was positioned incorrectly, the results would be less than desirable. The same holds true for casting for orthotic devices.

Further, the method of manufacture, the choice of materials, and the skills of the lab technicians all have an impact on the efficacy of the resulting orthotics. This may not be evident when the devices are first put into your shoes, but will make itself evident in short order. Always, and I mean always, be your own best advocate. If the devices either cause more pain, or fail to alleviate the pain that was the impetus for the orthotics in the first place, take them back to the doctor. work with them to get the devices either adjusted, or remade. Its your money, and it goes without saying (so why am I saying it:-) your feet.

Finally, the topic of proper break-in. If I took your feet and put them into a new position, and told you that was it, keep in that position from now on, well, I guarantee you will, within a short amount of time, come looking to sue me! Because making an abrupt change to joint positions is as much a trauma as the slow trauma that got you to this point in the first place. the difference is, its MUCH faster trauma.

Our bodies are really quite remarkable in their ability to compensate for slow trauma, some body types more than others, however. People with a loose ligament tone in their bodies, who often refer to themselves as "double-jointed," tend to compensate quite rapidly, and at more levels of the body. However, they also tend to show more problems in other joints that have compensated, over the long haul. People with very tight ligament tone, on the other hand, are not as good at compensating, especially in the short term. And of course, there are many gradations of ligament tone, and this is the main reason, besides the amount of time a particular condition has been present, that the proper break-in approach is critical to the success of foot orthotics. Let's say you are a 45 year old with bi-lateral post-club feet, and are just getting your first orthotics. And your ligament tone is on the tighter side. You may need as much as two to three months of gradual use of the devices before you are able to wear them full time.

The normal break-in recommendation works something like this - day 1, no more than 1 hour on your feet with the devices. Sitting does not count - only the amount of time standing, walking, running, count. day 2 - 2 hours. Day 3 - 3 hours, and so on. The "usual" break-in time is two weeks. But we who have post-club feet nearly always take more time to successfully break in our orthotics.

Finally, there is one other element that is absolutely critical to the success of orthotics - the shoes you put them into. If you put your new orthotics into those old, run-down shoes you have so painfully broken in, I guarantee the orthotics will fail, at least to some degree. I have always recommended clients either buy new shoes, or get their old ones repaired and re-balanced. The orthotics need to be in as neutral an environment as possible especially at the start of the orthotic usage. By the same token, the kinds of shoes you place the devices into also makes a difference to their success. Higher heels (sorry, ladies!) are not going to give as good a result, because higher heels make the foot slide forward. No surprise there - the foot was not designed to be always walking down hill!

Our feet start off with many disadvantages. The entire purpose of foot orthotics is to attempt to regain for our feet some of those lost advantages. It is important that we give as many possibilities for success as we can, for the ultimate success of this form of therapy.