Orthotic Information & Footwear Adjustments

Disappointed with your orthotic supports?

More and more patients are attending our clinic who have previously been issued with orthotic supports. Many of these patients are extremely disappointed that their supports have either been too uncomfortable to wear or that wearing them has made no appreciable difference to their symptoms.

Patients will often say things like “I just feel like I need more support”. In my opinion there are two main reasons for the lack of positive outcomes in these patients but before looking at those it may be worth looking at what the results of your devices not working are. Firstly and most importantly you are still in pain.

Secondly you may have developed some distrust of Podiatrists, particularly if you have paid a large amount of money for supports at a private clinic. If seen through the NHS system you may be frustrated that the whole process  taken up to so long. Finally and most worryingly you may have been told that as your devices haven’t helped, you will need to be referred to a surgeon for a possible operation.

Just a few of the devices brought to the clinic by patients who either couldn’t wear them or got no benefit from them.

How to Check if your Orthoses Fit

Many times, I receive questions from people who have either purchased orthoses or who have been issued orthoses through the NHS. The questions generally are around whether their devices fit properly and how they can check the fit of the devices.

There are three common reasons why patients have doubts about the devices they are wearing;

  1. Because they have some nagging doubt about the process the podiatrist who issued them went through.
  2. The devices are uncomfortable
  3. The devices have made no difference to their symptoms or as in many cases have made the symptoms worse.

If an orthotic does not fit correctly not only, can it be extremely uncomfortable because it overloads areas of the foot, but it also has the potential to cause real and lasting damage to the foot and the lower limb. In our clinic, we regularly take orthoses from patients which not only have not benefited the patient but also have exacerbated the patient’s symptoms. This can be very disheartening, especially if as in some cases the patient has spent large sum of money on what they were told were genuine custom orthoses.

A simple way to check the fit of your current orthoses is as follows. Firstly, take your shoe and sock off then bend your big toe upwards by about 40 degrees, this has the effect of raising your arch into a more corrected position. Then simply place your orthotic against the foot.

There are two things you should see if the device is properly fitting

  1. The device should closely hug the contour of the arch of your foot and
  2. You should be able to see the under surface of the device. This second observation tells you that the device is wrapping up and around the foot in the critical area of what we call the talonavicular joint and therefore applying the appropriate corrective force to the foot.

A poor fitting orthotic, note that the device does not hug the arch and therefore creases overloading in other areas of the foot. Not also that the under surface of the orthotic is not visible.

Properly fitting orthotic

A properly fitting orthotic which hugs the contour of the arch. Note that the under surface of the orthotic is clearly visible as it wraps upward around the foot creating the appropriate corrective force.

Why they may not fit

The biggest change in orthotic support manufacture in the past 20 years has been the manufacture of “Pseudo custom” orthotics. This means that instead of the casts your Podiatrist took being used as the exact shape for your supports, the manufacturer simply uses it as a template and uses a computer to come up with a device that is similar in shape but not an exact fit.

They do this by utilizing preformed generic profiles held inside a computer program. Sometimes the Podiatrist doesn’t even know that what they are being sold is nearest fit generic shaped support. You are told the devices you are buying are custom made and you are charged the full price of a custom orthotic but what you receive is a support made in a similar way to a support you can buy off the shelf.

By not fitting properly this devices can be extremely uncomfortable and may exacerbate your symptoms by forcing your foot into position which is detrimental to your particular foot pathology.

NHS Changes

Many NHS clinics have had their budgets so severely cut that they can no longer issue custom orthoses and instead now only issue off the shelf devices similar to those which can be bought in sports shops and pharmacies.

The devices have two main problems

1. They don’t fit as well as a custom orthotic and 

2.They have a very short functional life span, which necessitates them being continually replaced.

A fully custom orthotic should have a lifespan of up to 20 years. Not fitting properly means that they may actually exacerbate your symptoms.

Conclusion

The changes in orthotic therapy outlined above have in my opinion caused a severe deterioration in orthotic outcomes both in the NHS and in private practice and as such represent a real step back for our profession and for the patients we treat. Many of the patients that attend my clinic with ill-fitting orthoses do very well when issued with fully custom devices and many avoid having to go through painful surgical procedures.

By issuing poor fitting devices, which ultimately produce less than optimum results we are also putting more strain on other parts of the health provision system which ultimately creates more expense. Sadly it has also lead to decline in the public perception of what we in the Podiatry profession do.

For a fuller explanation of information above we have published an article which was published by David Hallowell in the UK Journal of Podiatry in 2017.

Common Footwear Adjustments

Common Footwear Adjustments

The most common footwear adjustments we are called to make are to the midsole of the shoe. These may be simple heel raises for patients with severe leg length differences or they may be angle wedged to allow force to be applied to the foot in a particular direction and thus reinforcing the function of any device being used inside the shoe. We can also make accommodative changes to the upper of the shoe in order to reduce pressure on bony or soft tissue prominences.

Lump and Bump Bubbles

We can create a bubble accommodation in most shoes to facilitate lumps and bumps. This can be done with simple bubble stretching or by making a custom bubble insert.

Standard Heel Raise

Normally used in conjunction with a heel raised insole or orthotic. This allows a large leg length discrepancy to be reduced whilst not appearing obtrusive. 

Transverse Offset Rocker Facilitation Heel Raise

This is a heel raise which is set at an angle within the mid-sole of the shoe in order to facilitate the use of angulated rocker. The front edge corresponds to the fulcrum of the rocker and facilitates even greater function. This is used for patients who are severely laterally unstable and have a plantarflexion deformity but who have enough mobility in their rearfoot to allow them to be rocked both forward and medially 

Eversion/ Inversion Wedging

Used in conjunction with a stabilising orthotic, this modification prevents compression of the midsole laterally or medically and therefore augments the function of the device inside the shoe.