Ep.31 Orthoses in Clinical Practice with Sophie Fitt
Feb 03, 2024
Jason Agosta
Are custom orthoses the panacea for podiatric woes, or is there more to the story? Sophie Fit of Fitzroy Podiatry rejoins us after the triumph of our metatarsal stress fractures discussion to unravel the complexities of orthoses in clinical practice. Our conversation cuts through the noise to lay bare the diverse ideologies and methodologies podiatrists bring to the table. It's an inviting look behind the curtain of patient-specific treatments, where one size never fits all but tailored solutions reign supreme.
Sophie's seasoned perspective shines as she walks us through her judicious approach to orthotic intervention, a testament to her expertise and dedication to patient care. She champions the diagnostic prowess of temporary treatments like taping before committing to custom orthoses, highlighting their instrumental role in her decision-making process. Equipped with high-quality foams and bespoke metatarsal domes, Sophie artfully illustrates her success in providing long-term relief for forefoot maladies. For practitioners and enthusiasts alike, this episode is an enlightening journey through the craft of creating comfort and the art of personalized care.
This podcast is recorded and produced on Naarm and Bunurong the traditional lands of the Kulin Nation. We pay our respects to the elders, past present and emerging and the land, seas and skies for which we all live.
Are custom orthoses the panacea for podiatric woes, or is there more to the story? Sophie Fit of Fitzroy Podiatry rejoins us after the triumph of our metatarsal stress fractures discussion to unravel the complexities of orthoses in clinical practice. Our conversation cuts through the noise to lay bare the diverse ideologies and methodologies podiatrists bring to the table. It's an inviting look behind the curtain of patient-specific treatments, where one size never fits all but tailored solutions reign supreme.
Sophie's seasoned perspective shines as she walks us through her judicious approach to orthotic intervention, a testament to her expertise and dedication to patient care. She champions the diagnostic prowess of temporary treatments like taping before committing to custom orthoses, highlighting their instrumental role in her decision-making process. Equipped with high-quality foams and bespoke metatarsal domes, Sophie artfully illustrates her success in providing long-term relief for forefoot maladies. For practitioners and enthusiasts alike, this episode is an enlightening journey through the craft of creating comfort and the art of personalized care.
This podcast is recorded and produced on Naarm and Bunurong the traditional lands of the Kulin Nation. We pay our respects to the elders, past present and emerging and the land, seas and skies for which we all live.
Speaker 1:
Welcome back to Simply the Best Pediatry, where we want to pass on simple tips to enhance your best practice. This is part three of our orthoses in clinical practice episodes and, moving on, I spoke to Sophie Fit who is from Fitzroy Pediatry. Sophie has contributed to this show previously with the hugely successful episode 18 on metatarsal stress fractures. Here I spoke with Sophie regarding her use of orthoses in clinical practice, speaking to five or six pediatrists getting their opinions on just philosophies, the ideology of the use of orthoses in practice, and the second part is what are you actually using? So it's quite brief, but just getting an overview from lots of different people. Basically there's no right or wrong, it's really just learning what people are doing. So others can learn from these short discussions but also realize that there is a big variation in what we do with things and it is very much practice related.
Speaker 2:
Totally.
Speaker 1:
So the first question to you, Sophie, and thanks for coming back on Our episodes. Have gone through the roof, so I really appreciate your contribution to simply the test.
Speaker 2:
Metatarsal fractures has gone through the roof, so yeah, I saw it in right back to you. When you said that Nice comment, I meant to say that you do make it very easy. So I reckon people have gone home. I wonder, or maybe they question how they're diagnosing them and they just thought that that's something they want to learn more about. I don't know, yeah. Well, I mean that's the aim of the show Differentials. I don't know.
Speaker 1:
Yeah, it's just a common thing and you know people just want clarification and really I suppose if you gain some understanding that's great. But you know it's a topical point, like as is this with orthosis and podiatrists. So, just to begin with, the first thing is so, and obviously this has changed for all of us over time. But what's your sort of sort of approach to using orthosis clinically, like when do you decide to use something and you know what sort of the criteria you might use in using orthosis for solving problems and treating people clinically?
Speaker 2:
Very rarely use an orthotic or prescribe an orthotic without testing. So, for example, I wouldn't prescribe an orthotic without first using tape for an example, so altering the posture of the foot, using tape to then see how it might respond if an orthotic was included down the track. What I'm saying is I don't generally just go straight to orthosis. There's usually a few steps before the orthotic prescription occurs.
Speaker 2:
And where I've come to or I guess how do I best say this is the pathologies or presentations that I find I'm using orthosis more is when temporary modalities for forefoot presentations so felts and foams and various other things that I may have tried with a temporary sort of purpose have been successful, I may move forward with an orthotic to then create a more permanent solution to what that strategy has created for the patient. So I really like orthoses with forefoot offloading. I really like, in the use of, say, any sort of first MTP presentation, be it sesamoids, halix, limitus rigidus, even some HIV stuff, when I can get in there and prescribe something with some really good foams that are, you know, manufactured in a much cleaner and better way than I can create in the clinic. I find the six to 12 months, 12 to 18 months and more years of relief that a patient can get from that strategy is really, really helpful. Which is probably going to sound a little bit different to what people would naturally think of orthotics I mean, we always think of, we often think of midfoot, rear foot stuff.
Speaker 2:
So I thought I'd come in here straight up and just say that the forefoot stuff is really is how I really like to use orthoses Creating metatarsal domes. You know through the laboratory that we work with being able to play around with different metatarsal dome fitness, position, density, all that sort of stuff is is just sorry about the background noise. That's just extra, a greater offering for a patient than what we've got in the clinic and that's where I think customs can help. But generally speaking, like when I'm working full time, I don't think I prescribe more than one pair of custom made foot orthoses per week.
Speaker 1:
Sure.
Speaker 2:
Like I think it would be, if I honestly don't think I. Oh, it's some weeks I wouldn't even do that. So customs aren't something I'm reaching for very frequently at all. I don't use the basis like a patient walks in with, you know, a pair that they've had for 15 years. They're looking very overworn, disheveled. That is not a reason for me to prescribe a new pair. That person's just another person I'm starting from scratch with.
Speaker 1:
Yeah, sure.
Speaker 2:
But if they've responded well to taping techniques perhaps felt or foam in their shoes and I am just looking for a more permanent solution, that is probably the number one reason or deciding factor for me to proceed with something, be it a generic prefabricated device or something customized.
Speaker 1:
Yeah, so very much a conservative approach initially.
Speaker 2:
That's what you're saying Very conservative and using them fairly sparingly, if I'm honest. Yeah, so in our clinic we use the form-thotics as a generic prefabricated device In the presentations of heel pain or any form of plantar fascia discomfort. I would probably prescribe a generic prefabricated orthotic, perhaps one in three or one in four plantar fascia presentations.
Speaker 1:
Yeah, okay.
Speaker 2:
And that is based on the research of my colleague, Glenn Whitaker, who compared the long-term if it's now comes of a steroid, corticosteroid injection with a generic orthotic and did use form-thotics and that had nothing to do with foot posture but was based purely on plantar pressures. And I, having trialed tape and I do use your taping technique in shifting the foot into greater supination to offload that pronation and the plantar pressures, if that has been successful and in consideration of other factors, especially footwear, lifestyle activities, body composition, that's where one in three patients with a plantar heel pain presentation will almost always be offered and probably walk away with a prefab from me and that's always with a discussion that this is a six to 12 month strategy. It's certainly not a long-term, long-long-term kind of thing, but it's absolutely with the next six to 12 months in mind and I find those patients go really, really well.
Speaker 1:
Okay, so the focus is being conservative and using preforms predominantly. That's what you're saying. Can I just pick up on that point you mentioned about the injection and the use of the foam inserts?
Speaker 2:
The outcome was that a generic prefabricated orthotic and he used the form-thotic brand was more successful in providing long-term asymptomatic outcome for plantar heel pain than a corticosteroid injection.
Speaker 1:
Right, so just having mild support was enough.
Speaker 2:
Correct yeah.
Speaker 1:
Yeah, okay, okay. So as far as when you do use orthoses, as far as preforms or you said, once a week you might make a custom or what are in preforms, you said you're using the foam styled EVA devices.
Speaker 2:
And then what about?
Speaker 1:
if you move on to the customs, what are you actually doing or what are you using there? You scanning or still taking plaster, or what's the approach?
Speaker 2:
So the material I most frequently would choose is a polycarbon or a carbon composite material and I in almost all cases will do like a polycarbon shell with a full length top cover. Very, very rare that I prescribed a three quarter polycarbon, so the sort of shell only device. But if that is the patient's overwhelming preference then of course we work with that. The reason I like a polycarbon shell with a full length top cover is it's the top cover more so that I'm utilising to add in the bits and bobs that I'm trying to, that I'm using to offload whatever I'm trying to offload.
Speaker 2:
Yeah, the forefoot padding, all that stuff, and it's the very start of my spiel about utilising custom puttothosis for forefoot pathology. So I like the polycarbon or the carbon composite shell. I just think it's a really nice bit of flex in it. It's not heavy like the polypropylene but it's very durable. Obviously, with the price point of CFOs, we are looking at durability and often those forefoot pathologies, for example, are of the chronic long term nature. So I really am looking at a long term device and I really like the lightness.
Speaker 2:
I like the advancement in that polycarbon material. It's not the only thing I use, but I do do a little bit of the dual density foams. I don't mind them in the right setting. But I love a polycarbon shell with a full length top cover. I always do a performance top cover, sort of the camberl base, the EVAs, with some pour on. I'm trying to create comfort, cushioning, support. I want the patient to step on it and really feel, ultimately, great comfort. That's what they need to feel. But then I know what's happening to the foot to offload, alleviate, address, whatever it is that requires.
Speaker 1:
Sure yeah.
Speaker 2:
You're floating.
Speaker 1:
So can you modify those devices yourself afterwards.
Speaker 2:
Yeah, I very rarely need to. But yeah, absolutely. So any grinding can occur, things can be pulled off, absolutely, things can be added, etc. But I tend to make the prescription very specific and I know exactly what I want the orthotic to look like and we're working with Orthotech at the moment and I think they're great. I often will call them before between sending the scans off and expecting the device back and get really specific about what I want and for those reasons I tend not to need to adjust them. But yeah, you can, absolutely.
Speaker 1:
Sure, okay, all right, that's great. So thanks so much for your input. I really appreciate your time once again and a very concise discussion, once again on expressing your expertise. I really appreciate it and hopefully, once I get all this together, it's going to be a good little series. So thanks a million for your time.
Speaker 2:
Thanks for letting me join in, jason, as always.
Speaker 1:
All right, thanks, I've seen you soon. Thanks for listening and that's the third of our Thoses in Clinical Practice series. Please get in touch if you want to chat and come on the show. Genie Orthoses are sponsoring these Orthoses in clinical practice episodes. More details of Genie Orthoses can be found at the webpage thegenieau thgniuau thegenieau, which will be on the show notes. You can also follow and support this show through the show notes. Thanks for listening and stay tuned for more Orthoses episodes. I'm Jason Agosta and thanks for listening.