Ep.29 Orthoses in Clinical Practice with Matt Mollica

Embark on a journey through the nuanced world of Podiatry with me, Jason Agosta, and the esteemed Matt Mollica from Windy Hill Podiatry, as we unravel the complexities of orthotic therapy in clinical practice. Our inaugural chat in this series promises to illuminate the various paths podiatrists take when incorporating orthoses into patient care, a subject often met with professional reticence. We address the elephant in the room—the apprehension surrounding the discussion of orthoses, possibly linked to the daunting task of mastering the evidence behind their use and the fear of being under-informed.

Together, we engage in an honest exchange, sharing our individual entries into Podiatry and how this has shaped our approach to treatment plans that seamlessly integrate orthotic therapy. The conversation covers the spectrum from the benefits of preformed orthoses—celebrated for their adaptability and patient comfort—to the vital role of cost-effective solutions tailored to diverse shoe types. We aim to foster a greater synergy between podiatrists and other healthcare professionals, enhancing the respect for Podiatric expertise and enriching patient care through collective wisdom and practical experiences. Tune in to this enlightening discourse and emerge with a richer understanding of the pivotal role orthoses can play in promoting foot health and overall well-being.

whpc.com.au (Windy Hill Podiatry Clinic)
@simplythebestpodiatry
@mashie_melbourne (Matt Mollica)
@australiangolfpassport
@jasonagosta
www.thegenie.au (genie orthoses)

Transcript

Speaker 1: 0:06

Welcome back to Simply the Best Pediatrie, where we want to pass on simple tips to enhance your best pediatrie practice. I'm Jason Augusta and bit of an overview of this show, which has been going for now 28 episodes and has been listened to throughout Australia, new Zealand, usa, the UK and Europe Fantastic feedback while on a break over January and had amazing feedback from Italian podiatrist Tomasso hi Tomasso in Italy. Thank you so much for your beautiful message. The most popular episodes have been Episode 12, running Technique, episode 18, metatarsal Fractures with Sophie Fit, episode 7 Footman Cancels with Anja Verena-Belling, episode 20 Practitioner Management with Fiona Allen from Launceston and Episode 19, fifth Metatarsal Fractures with Mark Blackney, orthopedic Surgeon. Thank you so much to all the contributors and hopefully this show has been a platform to gain some tips for your clinical practice. And although we have discussed many lower limb and footy shoes, it's time to delve into the use of orthoses in clinical practice. We will come back to clinical issues soon. This will be a series of several episodes, starting with discussing different podiatrists approach to using orthoses in clinical practice. We will then move on to review the evidence of using orthoses and then follow up discussing preformed orthoses and then cast it or scan custom orthoses.

Speaker 1: 1:45

I've been wanting to get this up for quite a while now. It's been a bit of time coming, but we're finally up and running and we start off speaking with Matt Molliker from Windy Hill podiatry here in Melbourne. Matt has been a podiatrist for 30 years and is passionate about his work, but also his mentoring of younger podiatrists coming through. Matt is a super keen golfer and also has his own podcast show, the Australian Golf Passport. This is a show about Australian golf courses, taking listeners on a tour of every golf course worth considering. These orthoses in clinical practice episodes are sponsored by Genie Orthoses and I must declare that Genie Orthoses have been my own preformed orthoses developed. More information can be found at thegenieau. I'll be discussing this along the way as we get on with our series Orthoses in Clinical Practice.

Speaker 1: 2:46

Matt Molliker and I start with a brief discussion. It's been a long time since we linked up. Thanks for listening. The show started and it was an idea. During a, I had an idea about doing it. Then it really was provided by giving a lecture and in the middle of it I thought no, this is not a lecture, this is a podcast and I reckon we can give so much more information out and it's just sort of grown and become much more diverse, and there's the more when I think about what we could do with the show. It just is endless. The topics are endless and, as you mentioned, there's just so many brilliant people out there and we're all doing things. Maybe some of the stuff we all do is similar and some of the stuff we do is like completely different approaches, and I love hearing about that.

Speaker 2: 3:37

And it's after a while. You'll look back and you think, geez, I've got to 60 of these and this is a big chapter book and people can go back and flip through it at any time. Or they're curious about oh well, just what happens if I inject someone for a P&A when they've got an infection. Is that going to oh yeah, I remember so that resource is there or they learn that and then apply that later on.

Speaker 1: 4:01

So yeah, well, that's the whole point of it, isn't it? Trying to pass on little pointers. So the point of this orthosis series and it will be a series of probably four, maybe even five episodes is that I'm really keen to blow this open and get people, as I said, use this as a conduit for transferring information and learning. And because we never hear the podiatrist speak about orthosis, and I'm not sure why that is. I think it's either because we don't feel like we know enough. We feel confused. We are confronted with our peers and is what I present good enough? Is it right? And then the other thing is also, is there any evidence for it? Which has obviously been really confusing over the years. Remember, this is very much a show that's directed to clinical practice and passing on best tips to enhance your practice. That's the whole mission. So I think there's several reasons why we don't hear the podiatrist speak about orthosis and, as you and I know, as we have progressed through the decades, it's actually okay to express yourself. But I just know what I do seems to fit a certain style and demographic in my rooms and it's not always right. I think we get to a point where it's like, yeah, there's no insecure feeling about it. Let's bust this thing open. And the last thing I will say I think podiatrists are guarded about their high ticket item when they might have all those other factors riding behind it, and so they don't talk about it.

Speaker 1: 5:51

Absolutely, I agree with all of that, and it's very interesting going online and speaking to lots of physiotherapists and I asked them recently I've asked five physiotherapists give me your first immediate thought of the podiatry fraternity that you're associated with. And every single physiotherapist said this. It gave me the same answer and basically it was resolved around a dispensary service for orthosis. Well, that's sad. Yeah, absolutely it is. Because we don't talk about it. We don't talk about our creativity or our knowledge behind materials. Maybe Do you know what I mean. Like we don't actually get that out there. So how would they ever know anything different From ARTA, from Footwork Lab, at the Brisbane National Conference this year? It was the best presentation of the use of orthosis, wasn't anything clinical, it was just absolutely brilliant. There wasn't many people in the audience, but it was something everyone should have heard. So here we are with our series of four to five episodes to discuss very openly our approach to using orthosis.

Speaker 2: 7:09

It should be a really valuable resource. I think It'll be good to get people to speak and just rid themselves of, whether it's a degree of insecurity or if they're feeling guarded about what they do. I agree with all those points that you said as far as hurdles in front of discussing orthotics.

Speaker 1: 7:33

I'm not sure where it comes from. Does it come from when we're at university? Oh, we need evidence behind that. It's like you and I both know clinically, it is all about the clinical approach and learning over the years of how to use orthosis clinically. The evidence gets pushed aside.

Speaker 2: 7:50

I think that's a big part of it. I don't reckon it's hard to teach creativity, and some people are going to be better at it than others. I'm surprised when I speak to the younger podiatrists, my younger colleagues, about how little they know about materials and how little they were exposed to different materials at an undergrad level. Maybe they never had a flame under them to begin with and so they never felt compelled to pursue that element of practice. Different people that I've spoken with in terms of what I've done to a shoe or how I've modified the top surface of an orthotic, or I ordered this material for this purpose, and they well, hang on, why would you? I've never done that. Can I see next time you do that?

Speaker 2: 8:36

or it blows me away a little bit and I'm a tiny bit sad because I think oh jeez there was a generation where they and I'm not just reminiscing, but there was a generation where that was central to what we did as orthotic practice as undergraduate students.

Speaker 1: 8:52

There was no doubt it made us better.

Speaker 1: 8:54

There was a lot of hands-on, wasn't there? Yeah, I'm not sure whether I'd like to hear how much hands-on goes on at the university. It's not a lot, well, I don't know, but anyway, because that's where it all starts. Unless you start there, you're not going to learn that creativity or that. I think it starts there. But if you haven't got that push or that starting point, what are you doing in the first few years to build upon it, and then the next few years? And by that time it's like 10 years of building upon, playing around or modifying things and getting your hands dirty. If that hasn't started, where are you 10 years later? Or 15? Not far along, just scanning a foot.

Speaker 2: 9:36

Yeah, I've been hoping. I've been hoping for a standard prescription, or you've got a regular prescription that you fall back on and hope that it achieves something.

Speaker 1: 9:48

So I went back in because I was never taught anything about a problem that I was going to see clinically.

Speaker 2: 9:54

To circle back to what you said before, that may be one of the reasons why some podiatrists don't freely discuss orthotic therapy, or they might be a bit guarded or reserved in talking about podiatry-centric topics, either openly or to other practitioners, because in the back of their mind they'll have this nagging doubt, where they doubt the model on which they learned, or they now know that, oh, that doesn't stand up to any sort of scientific examination, and there might be some nagging little element of them that thinks well, this feels like a bit of a house of cards and I'm not certain that I can just talk about my gut feel or what I do clinically or anecdotal presentations, because someone will shoot it down.

Speaker 1: 10:43

Yeah, that's like. Yeah, I get it.

Speaker 1: 10:48

So, there's an apprehension because of the lack of understanding. Yeah, yeah, but it starts back then. Yeah, okay, it's an interesting point, though isn't it Like going back to where it all drives from? If you don't know, how can you have that confidence?

Speaker 1: 11:01

So the first session is talking to people like yourself, in a variation of people, who will present how I approach the use of orthosis clinically and what am I using, and I think we'll learn. There is quite a variation and there's no right or wrong. That's the message to pass on. There is no right or wrong. It's what you do which feels right and what your style is in your practice, and obviously that will be dictated by several different variables clinically. And I think it's interesting, like talking about the progression of the use of orthosis even with the preformed part of using orthosis, how little progression there has been with what's on the market, like those preformed orthosis we were using 35 years ago are still being used to this day so readily in both podytrason physiotherapist practices, and the molding is so poor. The materials are incredibly poor. So I also want to move on to the different styles of orthosis, not just the approach of it, and try and pass on lots of tips. Incredible golfer Handicap. Give me a handicap Nine Woo.

Speaker 2: 12:15

It's not that it's going to be six by the end of this For an old man with confidence. No, I'm doing. I go to Keeser. Yeah, good, I get that. It's totally non-functional. There's no free weights and there's no mirrors, and on the youngest person there and you won't have to go.

Speaker 2: 12:30

I'm 10 kilos heavier than when I started six years ago and I've put on. I've put on no fat. My bone density is through the roof and I can squat and chin and do way more than I ever did, and the flares of back pain are much less. Thankfully Cool, so good.

Speaker 1: 12:46

Yeah, I am very sympathetic to back pain because I surfed in a contest two weeks ago and did four heat flat out as hard as I could. Pulse were good, got second in one, fourth in the other division, but I finished for the first time ever with my back stiffening up and literally squashed me the spasm and I was crippled for a week. I've just come out of it. I was my first understanding of the central, the centralizing of pain, being your focus. Yeah, it's brutal. It was my first insane. It was a next level understanding. Yeah, it was an interesting learning experience. First thing I want to ask you, though, because we haven't hooked up for a long time what fascinates you and is your passion with your work day to day? What is something about podiatry that you can tell me?

Speaker 2: 13:43

just still, lights your fire the removal of chronic pain. That's been a big problem in people's lives, that centralization of pain and that primary focus you described when someone comes back for a review. You've done this, you've done that. You see progress. Their symptoms are diminished, they're less frequent, their life is different. Just was I swear I was happier than the patient. Yeah, okay.

Speaker 1: 14:08

That's cool.

Speaker 2: 14:09

I remember thinking that that would be a part of podiatry when I was a year 12 student. Yeah, and I remember before putting it down as a subject or, sorry, as a course choice when I was a HSC student, I went to a session where Ann Marie Keenan spoke to secondary school students who would think of enrolling in the course and she alluded to that. And, yeah, ann Marie alluded to the fact that that would be one important facet of practice. Yeah, you got to experience that and provide that for patients on a regular basis in your working life.

Speaker 2: 14:46

And yeah, that was peeled from the word go and it's still there. Nailing unusual diagnosis is another one. I think we all sort of get a big buzz of oh I found this, or I put two and two together and I got this and this diagnosis that either alluded others or been present for a long time. And to get to the bottom of something obscure is always fascinating.

Speaker 1: 15:06

Yeah, beautiful. So what you're really saying is passion for people, and you're still getting off on the assisting of people and making things better. Yes, yes, I think that's a big driver, isn't it? As a health practitioner, if you've got that and that drives you into it, but it's obviously the great thing that can maintain you. Here we are 30 years later. Yeah, fantastic. Okay, so let's move on. Give me a brief overview of your approach or ideology of the use of orthoses in your rooms. I know it's a broad question, but there must be some sort of philosophy that you've developed over 30 years of practice.

Speaker 2: 15:45

Yep, definitely. I talk with patients about providing a recipe to try and resolve the issue that has brought them to me in the first place, and any sort of foot support, shoe, insert or thought it is simply one ingredient within that recipe. I've focused more as I've got older on pragmatic elements of management strengthening, stretching, load management, footwear, nutrition, visits with concurrent practitioners for a range of reasons, and I suspect that my orthotic prescription habits reflect that. Okay, the minority of what I use would be an individually manufactured prescription orthotic from a lab. I use them, but I probably skew to your end way more than most, I think the vast majority of what I do, more preformed orthoses.

Speaker 1: 16:43

Is that what you're saying?

Speaker 2: 16:44

Absolutely. I would modify those. I'd shorten them, I'd reinforce them, I'd add four foot padding to them. I'd put a mid foot wedge on them. I'd add a heel lift to them. I'd have a range of them that I'd turn to that have different magnitudes of rear foot inversion force, maximum medial arch apex, different locations of medial arch apex. They tend to be much more flexible and more low profile and probably softer than what a lot of our peers and contemporaries would use.

Speaker 1: 17:16

Yeah.

Speaker 2: 17:17

I'd probably modify shoes and have these pour on or other foam elements that I would shape and adhere within a shoe, like I would do a wheel balance to someone's footwear, in that in instead of issuing some sort of foot support as well.

Speaker 1: 17:35

Yeah, okay, preformed more than prescription, modifying them readily. And you just made a point that one of the reasons is because of the low profile sort of aspect of the preform devices and the flexibility. What's the reasoning behind that? Is your approach, or contributes to your approach, just the ease of use, or is there sort of these are the facts that you know these of use is a big part.

Speaker 2: 18:06

Yeah, and a number of patients who I can still recall in probably the first three or four years of my life where I'd gone down the path of issuing a prescription orthotic for them, and so a lot of work, a lot of time and cost had gone into it and it just it didn't fit within the shoes that they wanted to wear, needed to wear, preferred to wear, and sometimes, instead of wrestling with that patient trying to get them to make significant footwear change, I would acquiesce and say, well, I'm going to work with what you would prefer to wear, and that might compromise our outcome to some degree, but I think, as a patient, you're going to be happier with this process and you'll have some form of support in place or some sort of mechanical or podiatric intervention in place for a far greater percentage of the week.

Speaker 1: 18:50

Yeah, okay. I think you made a really interesting point, though, when you started. Is that this is one part of a treatment plan? Yeah, and that's crucial to realize that, I think as a younger practitioner.

Speaker 2: 19:04

Yeah, I remember early on in my time those treatment plans didn't have a lot of different items within them. You were relying on a modified route orthotic or an inverted style orthotic and the dilemma was does this have a heel post or a full length cover? It wasn't the dilemma about strengthening or stretching or reduction in running sessions per week or referral to someone that was yeah, exactly.

Speaker 1: 19:36

Well, I hope you're doing your toe strengthening right now, as Matt Dillnott's taught us, while your feet are under the chair in an extended position and you're pushing your toes into the ground. Matt, I hope you're doing that while we talk.

Speaker 2: 19:46

Got a little foot pro in the hallway at work and we use time to time.

Speaker 1: 19:49

Yeah, Okay, so what are you actually using? Are you using something that's already manufactured and then modifying it, or are there devices that are just set up as to what you want and you just issue them as they are?

Speaker 2: 20:07

A bit of both.

Speaker 1: 20:08

Yeah.

Speaker 2: 20:09

I'd occasionally use a form-thotic. I have a range of different ready-made preformed foot supports that are able to be modified what quickly and readily and reliably and repeatably, so that if that works for someone and they say, oh look, I want one of these in my golf shoes and I want one in my work boots, you can replicate that.

Speaker 1: 20:32

Sure, Do you think that's one of the easy parts of using the sort of ready-made or preformed orthosis that you can? It's pretty easy to replicate, isn't it?

Speaker 2: 20:41

Yeah, and I've become more and more cost sensitive as I've got older as well. I often think about the fee that I would give a patient and think, well, what else could they do with that money? And if I'm asking them to change footwear, see the doctor for some medication, go to the physio, have an injection or some massage sessions or get a stretching brace or something along those lines, in addition to other sort of orthomechanical therapies I find more manageable and I think a lot of the patients I see anyway appreciate that.

Speaker 1: 21:17

I think that is so much appreciation for it. I think it's easy for you, but they appreciate it. Some people are coming expecting like to unload tons of money on the high end ticket item, but I think, as you said, if it's one part of the treatment plan and you as a practitioner a little bit cost sensitive, this is about, again, the passion for people and caring. I think it makes a big difference. I think people are very, very appreciative of it. I think we should say that there are such a range of ready-made or preformed orthosis, as you mentioned. But you really have to be quite objective about the qualities, don't you?

Speaker 2: 21:55

Yeah, I think so, and I think you've got to be. I think you've got to ask yourself what you're trying to achieve and what characteristics each of those different products possesses. Is this going to be suited to this person in front of me? Are their needs going to be met by this? Is it compatible with their activities? Because there's a sufficient variation in them?

Speaker 1: 22:14

Yeah, do you find that many of the preforms are just too molded? They're too sort of set in stone? Yes, and what about the materials? Some of the materials? We were using them 35 years ago. It was like holy shit. Materials have changed so rapidly around us in every other domain.

Speaker 2: 22:38

Yeah, even in terms of environmental friendly levels they've changed. But bulk first step feel size that they occupy within shoes, their material properties and how they relate to their function, how much they'll deform. And yeah, there's this huge variation.

Speaker 1: 22:55

So those devices that? Yeah, so you're talking about the one from Hamburg, the little thing in global tech from Hamburg. Yeah, I have become. As you know, I use lots of preformed orthosis. I've become so frustrated with the materials and the contours that I just made sure eventually I had my own and it was all about minimal bulk, maintain the flexibility and being able to change that device in any way that I wanted to. It was really. It's really easy to use.

Speaker 1: 23:29

So that's where that my idea was born from. And the whole premise was having support without pressure. What more could we ask for? It's hard to achieve, it's super hard. That's why I started with that. I want support without pressure, knowing it was so difficult to get that perfect balance and you can't do it for every single person, but that was the aim and the driving sort of mission behind it.

Speaker 1: 23:58

So I've said this on this show before about the number one question I get from a new grad or someone who hasn't been they've been out for a few years is how come you only see two patients an hour and not three or four Thinking commercially early on in the piece, where what you have mentioned tonight is that you've had a fascination with the problems and helping that person. Yeah, and then the other thing. The second thing is talking about you discussing preformed orthosis and, as you know, that's a big part of my rooms. The other comment, the number one comment in that regard, is why are you doing all this? Why would you, why do you bother doing all this? Why don't you just send it off to someone? That's, they think, and it's going to be easy to do that.

Speaker 1: 24:46

Having someone organize everything for them who hasn't even seen the patient, and you and I both know the whole prescription thing, it's that confusing that. What are you going to prescribe? Hey, matt, thanks for joining me and kickstarting this orthosis series. I really appreciate your time and you are a senior practitioner in our industry and you should be very proud of who you are and what you've created and what you're doing for the younger practitioners. Incredible job, mate. Thanks for coming on and thanks Jason.

Speaker 2: 25:16

Pleasure. I'm honored. You asked me and it's been a pleasure to speak with you. I look forward to listening to to all the other contributors too.

Speaker 1: 25:23

To speak soon. Thanks for listening. And that's the first of our orthosis in clinical practice series. Please get in touch if you want to chat and come on the show. This is everybody's show, so get involved. This show does cost to maintain and genie orthoses are sponsoring these orthoses in clinical practice episodes. More details of genie orthoses can be found at thegenie g-e-n-i-e dot a-u, which will be on the show notes. You can also follow and support the show through the show notes. Thanks for listening and stay tuned for more orthoses in clinical practice series. Thanks for listening.