Foot pain is a common cause of absenteeism, reduced productivity and low morale among employees, particularly those whose jobs are dependent upon being on their feet.
About 25 years ago, research and development in the podiatric community gave podiatrists the ability to correct many foot problems caused by faulty foot mechanics. The key to treatment was to have an orthotic device fabricated from a neutral, or corrected position cast of the foot. Using about 20 steps at a podiatric laboratory, orthotics were designed to control each phase of the walking cycle from the moment the heel strikes the ground and absorbs shock until the push-off phase. Many foot problems that were previously unresponsive to conventional treatments could now be cured.
By the 1980s, some ski boot shops were selling orthotics and telling customers that they had to have an orthotic. Many retail stores started selling what they called "orthotics", but were in fact prefabricated, stock item, arch supports.
After a podiatric examination and diagnosis are made, a biomechanical prescription is written. A cast is then taken of the patient’s foot in the corrected, non-weight bearing position. An orthotic is made that accommodates normal motion and prevents abnormal motion.
The difference between an orthotic and an arch support is that an orthotic is designed for the dynamic motion of walking, while an arch support simply pushes up against the arch when the wearer is standing and is not corrective. Most arch supports are also stock sizes.
THE OVER-UTILIZATION STORY
As many insurers are aware, there have been increasing claims for orthotics in recent years. In fact, some insurers have experienced exorbitantly high claims for orthotics and many were prescribed by people who do not normally treat feet as a specialty. Research by the Ontario Podiatric Medical Association demonstrated that there were a number of retailers, and others who were regularly recommending orthotic devices, regardless of whether a diagnosis was made. Some people were selling orthotics literally off the back of a truck, while others would go into a company and screen all the employees recommending most or all would need orthotics and orthopaedic shoes.
By the 1990s, it seemed that just about anyone who had anything to do with health care was getting into the foot business and was recommending orthotics. Chiropractors, physical therapists, pedorthists and others were having patients step in a foam box, then dispensing basically a stock item arch support with or without modifications and calling it an orthotic device. They seemed not to understand that a foam impression of the foot is capturing the foot in a deviated or deformed position and is not corrective. Hence, problems would persist or recur.
Podiatrists argued that there was a great deal of over utilization taking place, and in many cases, orthotics were being dispensed to patients that were unnecessary and were, in fact, not really orthotic devices. Podiatrists pointed to their research as evidence that a neutral position cast of the foot is the key to obtaining a corrected three-dimensional foot impression for fabrication of a precise and effective orthotic device.
HOW A PROPER ORTHOTIC WORKS
Each foot is comprised of 26 bones and in many cases, people have abnormal tilting of the bones which causes the foot to compensate and roll in excessively (called pronation). Some people have the opposite problem, namely, a rigid, high arch foot structure. In either case, abnormal forces gradually impact upon the foot over many years. This creates overuse syndromes such as heel pain, plantar fascitis (arch pain), pinched nerves, bunions, knee pain and the like.
Some insurers have asked Lloyd Nesbitt of the Ontario Podiatry Association to evaluate patients and their families who had been told that they need orthotics and orthopaedic shoes. In many cases, although the orthotics may have been necessary, frequently they were made incorrectly, or were not designed to control the foot in motion. It was indicated to the insurers that the likelihood of a subsequent claim for orthotics within a six-month period or a year would be high. (Properly designed orthotics should normally last at least three years.) Furthermore, in most of the cases, the insurers were advised that orthopaedic shoes were not necessary. The shoes were being sold to the patient to accommodate a thick orthotic, when in fact, a thick orthotic was not necessary in the first place.
The investigations also disclosed that claims of $1,000 to $1,500 per patient for foot orthotics were not unusual. In some cases, entire families had been prescribed orthopaedic shoes and so-called “orthotics” with claims of $3,000 to $5,000. Properly designed orthotics prescribed by podiatrists characteristically cost in the range of $250.00 to $500.00.
FOOT CARE TODAY
In British Columbia, Alberta, Ontario and Quebec, podiatrists are recognized as the pre-eminent foot care specialists among the regulated professions. Yet many others provide foot care include chiropractors, physiotherapists, occupational therapists, pedorthists, massage therapists, nurses or even shoe salespersons.
Many of the allied health practitioners mistakenly feel that foot care means orthotics. Podiatrists know that there is much more to foot care. A thorough examination and diagnosis are required before the appropriate course of treatment can be determined. Often podiatrists use treatments other than orthotics to address the diagnosed problem including surgery, palliative care and debridement of lesions, padding, taping, exercise or stretching and strengthening.
COMPUTERS AND ORTHOTICS
In recent years there has been a great deal of interest in gait analysis. Technology has evolved to the point that a person can walk over a force plate and a very hi-tech digital presentation is immediately available on a screen showing weight-bearing patterns of the foot. While these presentations are primarily two-dimensional, they certainly look impressive. The first question with respect to this approach is the qualifications of the person who is examining the patient. If someone is not fully trained in podiatric medicine and biomechanics, he/she may not be qualified to make a diagnosis. In fact he/she may not be legally permitted to make a diagnosis of the foot problem.
The illusion that is often created is that if there is a hi-tech gait analysis, then it stands to reason that a hi-tech orthotic device will follow. Unfortunately, in today’s marketplace most of the orthotics that follow from this type of analysis are basically a stock item. Depending on the practitioner recommending these devices
following a computer analysis, there may be some modifications, such as a variety of top covers, etc.
There is currently a controversy as to whether a cast of the foot is the preferred technique, or a stock item device is just as good. Podiatrists argue that a three-dimensional representation of the foot by a plaster cast will offer optimal correction and that foot care is best left to those who are trained in this area.
In Ontario, the Ministry of Health has indicated to the podiatry profession that it realizes that the entire field of orthotics needs a "shaking out", much like the audiology profession of years ago when people were selling hearing aids door-to-door.
The Ministry has indicated to the Ontario Podiatric Medical Association that it will take several years for legislation to be fine-tuned so that podiatrists (and likely chiropodists) will be the recommended providers of orthotics. The ministry has further advised the Association that in all likelihood the insurance companies will be taking the lead on the economic front in terms of limiting coverage for orthotics.
BOTTOM LINE FOR INSURERS
Some insurers have restricted orthotic coverage so that the only acceptable providers of orthotics are podiatrists using plaster casts. As a result, they have seen claims drop by over 50 per cent.
This paper was written by Lloyd Nesbitt, DPM, Insurance Liaison Committee Chairman of the Ontario Podiatric Medical Association. Any questions should be directed to him at (416) 733-8533, 4950 Yonge Street, Suite 2414, North York, Ont. M2N 6K1.