What are the indications for orthotics (orthotic devices) fitting with podiatry?

Indications for Orthotic Fitting with Podiatry

Patients should be referred for orthotic fitting with podiatry when they have foot deformities, biomechanical abnormalities, or specific medical conditions that increase the risk of foot ulceration, pain, or functional limitations.

Primary Indications for Orthotic Devices

1. Diabetic Foot Conditions

• Charcot Neuro-osteoarthropathy (CNO)

  • Patients with diabetes who have been treated for active CNO and are now in remission 1
  • Presence of foot deformity resulting from CNO 1
  • Joint instability in the foot and ankle following CNO 1

• Diabetic Neuropathy

  • Loss of protective sensation with foot deformities 1
  • Abnormal plantar pressure distribution 1
  • History of previous foot ulceration 1
  • Signs of abnormal loading (hyperemia, callus formation) 1

2. Foot Deformities

• Toe deformities (hammer toes, claw toes) 1
• Hallux valgus (bunions) 1
• Prominent metatarsal heads 1
• Midfoot collapse or instability 1
• Pes planus (flat feet) or pes cavus (high arches) requiring biomechanical support

3. Plantar Fasciitis

• Persistent heel pain not responding to conventional treatments (NSAIDs, stretching) 2
• Morning pain with first steps 2, 3
• Pain exacerbated by prolonged standing or walking 3

4. Other Conditions

• Epidermolysis bullosa with foot deformities 1
• Recurrent callus or hyperkeratosis formation 1
• Neurovascular hyperkeratosis (especially over calcaneum and hallux) 1
• Lower limb musculoskeletal pain related to foot biomechanics 4

Clinical Assessment Findings Indicating Need for Orthotics

Biomechanical Evaluation

• Abnormal gait pattern affecting foot loading
• Excessive pronation or supination during stance phase
• Limited joint range of motion in the foot and ankle
• Leg length discrepancy affecting foot mechanics

Physical Examination Findings

• Callus formation in weight-bearing areas 1
• Foot deformities that affect weight distribution 1
• Inadequate footwear with signs of abnormal wear patterns 1
• Pain on palpation of plantar fascia insertion 2, 5

Risk Assessment

• High-risk patients (diabetes with neuropathy) with foot deformities 1
• Patients with previous foot ulceration history 1
• Patients with impaired circulation (absent pedal pulses) 1

Types of Orthotic Interventions Based on Clinical Presentation

For Diabetic Foot/CNO

• Custom-made orthoses for patients with significant deformity 1
• Below-knee customized devices for patients with joint instability 1
• Extra-depth footwear to accommodate orthotic devices 1

For Plantar Fasciitis

• Prefabricated orthoses with firm foam support 3, 5
• Custom orthoses for cases with significant biomechanical abnormalities 3

For Skin Conditions (e.g., Epidermolysis Bullosa)

• Orthoses with silver-fibred coverings to reduce friction 1
• Accommodative orthoses to minimize pressure on vulnerable areas 1

Common Pitfalls and Caveats

1. Inappropriate orthotic prescription: Not all foot pain requires custom orthotics; prefabricated orthoses may be equally effective for conditions like plantar fasciitis 3, 6

2. Inadequate footwear assessment: Orthotic devices must be paired with appropriate footwear that has adequate depth, width, and length 1

3. Overlooking the need for orthotic adjustment: Initial orthotic fitting may require follow-up adjustments to optimize effectiveness

4. Focusing only on the foot: Lower limb alignment issues may require comprehensive assessment beyond just the foot 4

5. Delayed referral: High-risk patients (especially those with diabetes and neuropathy) should be referred promptly when foot deformities are identified 1

Remember that orthotic therapy should be part of a comprehensive approach to foot care, especially for patients with diabetes or other conditions that increase the risk of foot complications. Early intervention with appropriate orthotic devices can significantly reduce the risk of ulceration, pain, and disability.