This article is part one of a four part series on building an accurate and effective custom foot orthosis. It is assumed that the reader is a busy, overworked and underpaid practitioner, who must work quickly and efficiently, yet produce a high quality outcome, in this case, a foot orthotic that achieves the goal of symptom relief, improved biomechanics, and mitigation of future pathology of the lower extremities. As financial pressure mounts upon medical providers through lowered reimbursements and increased overhead expenses, adapting procedures that increase efficiency through time and resource management within the clinic setting is paramount to the success, or even survival of your practice. Digital scanning and ordering of the orthotics goes a long way in cutting down on the time necessary to process custom made orthotic devices, eliminating the need for materials used in the past to capture the foot in neutral position, making copies and filing of order forms and other paperwork, packing and shipping of casts, and waiting for the lab to ultimately receive the casts. How else can we increase our efficiency within our biomechanics practice?
Creating a superior orthotic device should always start with a gait analysis of the patient. In order to gather the necessary information obtained during the gait analysis a simple checklist should be created. I have found it helps to break down the exam into segments, starting with head, then shoulders, then arm swing, then pelvis, knees, and finally the feet and ankles. Have an assistant or scribe fill in the checklist as you watch and remark upon your findings. Two passes in a relatively long hallway (15-20 feet) should suffice. One minute on a treadmill also works. Next, check the static stance position, are the feet and legs symmetrical? Calcaneal stance position? Medial arch morphology? Place the patient in neutral position while standing, what changes do you observe from their resting position to their neutral position? Have the patient rotate their upper body fully left and right while their feet stay still, Is there any motion possible in the 1st MTPJ while in a resting stance, does it improve in a neutral stance? Next perform a non weight bearing exam, check for ankle dorsiflexion, subtalar joint range of motion, midtarsal range of motion, any forefoot deformity. Again, look for asymmetry.
All these findings, and more can be achieved in under 5 minutes, if you have a repeatable routine, a trained assistant and a simple checklist. With the proper records you can justify your evaluation and management code, and refer back at a later date if necessary to determine if adjustments need to be made to the orthotics. At this point, the patient can be scanned or impressions be made. All the while you can explain to the patient what you are doing and why you are doing it. Try to keep answers to the patient's questions brief and direct. I always found it helped to use analogies of familiar situations, like an optometrist making eyeglasses or a dentist making a crown or dentures.
Further enhancement to this process includes having the information regarding the patient's insurance status of orthotic benefits and patient financial responsibility ahead of time will eliminate waiting time while the patient is in the office. Have plenty of models and charts available to the patient to observe and further their understanding of biomechanical conditions. Have your treatment plan worked out for future visits or possible procedures, schedule the patient for their dispense visit at this time.
In our next three posts we will go over a method for building an effective custom foot orthotic. I would encourage you to go to the KevinRoot Medical website and review the various orthotic types, materials and modifications available to you and your patients.
