Ep.33 Orthoses and the Art of Podiatric Excellence: Insights from Matt Appleton

Join the reflective journey with Jason Agosta and the esteemed podiatrist Matt Appleton, as we unravel the intricacies of orthotic therapy. With Matt's extensive background in private practice, sports medicine, and shoe retail, our conversation meanders through the evolution of podiatry, shining a light on the artisanal craft of orthotic fabrication and its critical role in clinical expertise. We share stories that celebrate the lessons learned from patients, and Matt imparts his wisdom on keeping the zeal for podiatry aflame through a career rich in diversity.

This episode isn't just about the who's who and the what's what; it's an ethical exploration into the heart of patient-centric care, dissecting the delicate balance between necessity and financial influence in the prescribing of orthotics. We lay bare the ramification of over-prescription, and why follow-up care isn't just an afterthought—it's a cornerstone of effective podiatry. As we navigate the practical skills essential for modifying orthotics, we underscore the educational void in current teaching methods, advocating for a musculoskeletal curriculum that does justice to the hands-on finesse required in our field. Listen in for a discourse that promises to enrich your perspective on the craft and challenge you to reflect on the impact of your work in podiatry.

@simplythebestpodiatry
@jasonagosta
www.mattappleton.com.au
thegenie.au

Transcript

Speaker 1: 0:06

Welcome back to Simply the Best Padietry, where we want to pass on simple tips to our hearts, your best practice. I'm Jason Agosta and we continue on with our orthoses in clinical practice sessions, speaking with Matt Appleton, who has been in practice for more than 36 years and practices in Peran here in Melbourne and also originally in Mansfield. Matt has had a diverse career in private practice, being involved in sports medicine practices and also a shoe retail business. These orthoses sessions are sponsored by Genie Orthoses and you can find more details on the webpage thegenieau. Thegenieau Genie Orthoses are 3D printed preformed orthoses that have been developed by myself with an aim to have support but zero or minimal pressure. The webpage is thegenieau. Here is Matthew Appleton, so joining me now is Matt Appleton, a long time podiatrist, who I've known for years and years, and I think you were a few years ahead of me, matt, but thank you for coming on. Simply the Best Padietry.

Speaker 2: 1:28

Thank you for having me and thanks for what you're doing with the podcast. I reached out to you an hour after I stumbled across it and thought, sure, that's a good thing and good to see people with a few years under their belt giving back. So I thought let's just see if Jason is interested in hearing what this old fella's got to say.

Speaker 1: 1:50

Yeah, it's been good actually and thank you for your feedback. I really appreciate it and I think I said to a few people but this is everyone's show. This is I'm just hosting a show for everybody. This everyone's show whoever wants to host or come on is more than welcome and it's more about just getting information out there and, if we can pass on a few tips to help people out, fantastic. So hopefully we can give it a little bit back.

Speaker 2: 2:20

Exactly right and probably, like yourself, starting to worry a little bit about where the next podiatrist is going to come from, with lack of people, perhaps taking up the profession and then dropping out after five years, and I don't know what your feelings are, but it probably takes you two or three years to start to get good clinically and then from there you grow Absolutely.

Speaker 1: 2:43

Yeah, I remember when I started it. I think it took me three years to get busy and probably five years to get really super busy and certainly have a handle on a lot of things. It took that long for sure.

Speaker 2: 2:59

It just takes time to develop your craft and it takes time to develop your confidence, and you just need to see things to kind of sometimes get a handle on them and learn from them.

Speaker 1: 3:11

Sure.

Speaker 2: 3:12

I've always kind of said that patients can teach you as much as you necessarily teach them, and if you have a session where you think you haven't learned anything off some of your patients who have come through, then it's probably time to give it away, and fortunately that hasn't happened to me yet.

Speaker 1: 3:30

So what has kept you in after all these years? What sort of things have you been passionate about?

Speaker 2: 3:39

Well, I guess I've been lucky to have multiple facets to my career. I've always stayed clinical to a certain extent, but that's had been flowed a little bit according to distractions on the side and distractions probably the wrong word. But in the early days I had a pretty big involvement in an orthotic laboratory and was very heavily involved in what was the old Sports Medicine Centre as a Victoria, where I was a partner and on the management team there until we got bored out. And then, when we got bored out, I had some time and money because I wasn't consulting five days a week and I've had the idea for a technical running shoe store and thought well, you're pretty much out of excuses now You've got time, you've got the money. You better pull your finger out. And so I had 13 years at retail. Yeah, ok.

Speaker 1: 4:28

That was active fees.

Speaker 2: 4:29

Yeah, yeah, and it was a great time and really enjoyed it. Yeah, you know, I kind of chaired the group through the time that I was there and I was on the buying group the whole time, so we were buying a fair few pairs of shoes to see in it. That's great, yeah, if you'd say, but great diversity.

Speaker 1: 4:49

I think that's what you're saying. You've kept it really diverse. You've had lots of things going on.

Speaker 2: 4:53

That's true and you know the clinical level. I've kind of evolved and changed a lot of what I do. I've always done musculoskeletal medicine as the primary passion and it was the primary passion that kind of made me choose. But I actually, way back, I was trying to decide what I was going to do at the end of what was then HSC and I kind of saw and did some work experience after I finished my HSC, did some work experience with a well-known at the time sports pro actress. I thought this is a young profession. Yeah, I was just noodles of opportunity and the other things I was considering an allied elf were pretty mature professions. I thought I'd be able to get a leg up the tree quicker if I go down the path of podiatry. And you know, back in the day when you used to make orthotics and the like, I kind of grew up with a father who's a carpenter, so I've always worked with my hands and stuff.

Speaker 1: 5:51

Yeah, perfect.

Speaker 2: 5:53

I still do a lot of my modification work in my own laboratory up at the farm. I think that's important for just giving the 5% of the patients sometimes Sure.

Speaker 1: 6:08

That's one thing that's come out of all these orthosis sessions we've discussed is the hands on approach and the need to be practical.

Speaker 2: 6:20

Yeah, exactly, yeah, very hard to troubleshoot if you haven't made something from where to go. And if you have made something from where to go as we had to back in the day, then that gives you a bit of an idea and then, with having had a lab and had to teach people to make the things, yeah.

Speaker 2: 6:36

And then I'm a bit fussy. I'm a bit fussy with shapes and positions and I don't think it's it's certainly not necessarily any lab's fault with regard to padding and all those sorts of things. It's just difficult to do that if you haven't necessarily got the patients foot in front of you. And then you add in my level of fussiness and sometimes it's just right, I'm just going to do this myself. Yeah, okay, and it's quicker. Often, you know, I can turn the orthotics around much more quickly.

Speaker 2: 7:07

I have never gone down the path of having a grinder and stuff in my clinic. I always take it away to do I do some real simple things in the clinic, but if it's anything more significant I'll take it away. I'm not going to put my hands out, in part because I was spoiled when I had a lab. I knew what the gold standard of equipment was. And then you start to go if I've got this, I can do that perfectly, and I forgot this piece of machinery and do that perfectly. I can't have all that in the clinic and you know I'm in big multi-disciplinary clinics and I don't like to have dirty rooms with grinders and stuff in it, and so I just don't do much of it in the clinic, but because I'm at my farm a lot, I can just turn it over quickly, sure.

Speaker 1: 7:48

Yeah, so now you're working at two different locations, one in Melbourne, here in Peran and also Mansfield. So my question is with those two varying locations one being city based and one regionally what are the differences in what presents to you?

Speaker 2: 8:07

Well, I've always been a bit Someone say narrow minded in so far as I don't only do muscular scleral medicine and always have in my private practice. And so when I started in Mansfield that was a bit of a problem because there was demand for general treatment as well. So I would screen every single patient because it's an awkward conversation when someone is not with whatever they need from a general treatment perspective and they look at your room and you go well, this doesn't look like a standard, but I have room and then you go to Alameda Cato and have any instruments. So I've been single minded on that and in the early phases I supplemented that goal to be just doing muscular scleral by doing nursing home work and hospital work and all those sorts of things.

Speaker 2: 8:55

But I've been in the sports medicine centers, life care Paran forever, a long, long time, and have been consulting in Mansfield for probably five years now. I've had no part here for much longer than that. So I wasn't sure about that, Having always worked in a big clinic with all different practitioners around me and you know gold class radiology downstairs and I thought, oh yeah, well, I know there's need up here and country people just know how to bust themselves really good, from horses to motorbikes to snow skiing and everything else in between. And we're very fortunate in Mansfield there's lots of doctors but they're flat out and they were just really happy for someone who knew something about feet and trauma. I just get lots of it, so I get.

Speaker 2: 9:53

So my practice is kind of evolved over the journey from what you would see in sports medicine, podiatrist, what I call myself a muscular little podiatrist now because I really like trauma. So I say you keep trauma up here in Mansfield and I will go in because I'm not far away from the clinic. So if I get a call and someone's hurt I'll go and see them, just because I like it I can. And so yeah, it's kind of the practice. I run up here.

Speaker 1: 10:22

Okay, what about for the skiing industry? Do you do much for the skiing industry? Considering a location there?

Speaker 2: 10:29

Not directly, but you see plenty of patients who have either got boot fit issues or have had some on the, on the snow and yeah, but I don't go out of my way to promote it. Nice family, don't do anything on the mountain, the ski myself.

Speaker 1: 10:44

Sure. So these sessions contribute to, I suppose, the mission of simply the best podiatry, in that we want to pass on simple tips to enhance people's best podiatry practice, and the orthosis sessions revolve around learning what other people are doing and what you're using clinically, so we can pass on a bit of information. So the first question is what is your sort of philosophy or your sort of ideology behind the use of orthosis in clinical?

Speaker 2: 11:18

practice.

Speaker 2: 11:19

So I guess broadly speaking it's a tissue stress kind of person, very big advocate for what's known, the diagnosis is, before we start trying to change anything, and what what's injured and how I change the load on it to have a positive impact.

Speaker 2: 11:37

Yeah, and that would be in its in its broadest sense. And I don't mind whether I change that load by training, by shoes, by insoles being or generic orthotics or prescription orthotics. And one of the things I've tried to say to the younger guys have worked with us over the years is don't make financial decisions either for your patients. Just lay out what their options are and let them kind of decide, yeah, within the parameters that you just never know what their goals and what their financial position is. And it's a game podiatrist who reckons they know that if you change to this shoe or to this orthotic or to this over-the-counter device, that the prognosis is this. I often give people options, but I'm a big advocate of wanting to demonstrate to the patient that I can change their pain before I start necessarily wanting to change shoes, insoles, whatever.

Speaker 1: 12:41

Sure exactly. Well, that's a big part of what you just said about orthosis being one of the many aspects of a treatment plan, like taping and training, and you might use lifts or something simple to try and learn. You know how you can help and how the patient's going to respond.

Speaker 2: 12:59

Yeah, absolutely, and you know I kind of advertise a little bit for second opinion works. I can get patients who present with what happened this week. A patient came in and literally had a basket full of orthotics and it's like, even for me I was like just stunned. It's like, oh no, it's mind-blowing.

Speaker 2: 13:17

And it's like what are all these for? And she said well, you know, they just kept saying it's not right, it's not right. So I just kept getting new orthotics. And so I have another kind of line with my patients, especially if they've seen other people, that if they're unhappy with my orthotics they can throw them at me or the table, but they're not allowed to bring someone else's in and throw them at me, because sometimes I'm sure it's happened to you you get patients who come in and they're in the hole financially, they know better functionally and they've still got their pain and they're just grumpy as hell with the most glitter world, which can include everyone and anyone and certainly put on interest as well.

Speaker 1: 13:56

I think that also gets back to what you said earlier about the practicalities of dealing with orthosis and being able to modify them and troubleshoot and fix problems and being able to do that on the spot quickly and easily for the patient. That's a big part of it, because if you can't do that and you're not used to it, practically that person's pissed off and they just go and get another pair somewhere else instead of trying to fix the problem.

Speaker 2: 14:21

You know that's exactly right. In a way I've kind of structured the billing is I let my patients know that for a certain period of time, up to three months in advance, I'm getting their orthotics or post them getting their orthotics. The reviews are included and they include, if I want to change their covers.

Speaker 2: 14:41

I don't want to put any reason that I want to come back from a financial perspective so that we can get things right, and I probably modify 30 to 40 percent of my patients' orthotics, and sometimes it's because I'm not happy with what I see while I'm reviewing them, and sometimes it's because I'm not getting the desired result, or a combination of both.

Speaker 1: 15:08

That's a good point. There's a huge number of modifications needed, isn't there?

Speaker 2: 15:13

Yeah, there is, and by the time you use Curious and send them to a lab and then maybe the lab does what you want them to do. Maybe you don't tell the lab what you really need accurately enough, because communication is difficult sometimes when you're into the modification world. What you're thinking is not what the text is thinking and it could be a two-week turnaround and a person's paid a lot of money, had them three weeks come back. You're not getting desired results and then there's two more weeks before they get them again. I think that model is particularly effective.

Speaker 1: 15:46

That's done. I think these days that is done. I think you've got to get your hands on it.

Speaker 2: 15:52

Yeah, well, they don't teach at Jase, so how are they going to know?

Speaker 1: 15:55

Well, there's another common thing message that's come out of all these sessions. It seems that everyone's saying the same thing that the practical skills, and the only way I've learnt that is just from having younger people come through. And I think I said on one of the earlier sessions one of the most common questions is why are you getting your hands dirty and doing all this? Why can you bother doing that? Why don't you just send it off for someone else to do it? This has come up repeatedly in these sessions.

Speaker 2: 16:25

Yeah, I'm not surprised and I think way back to the days I used to do it. I used to do it in the time of the Alfred. We'd have students there and we used to share the orthotic lab with the authors. So it was a great lab and even back in those days when carotidists were required to make orthotics, I'd just get them on one of the linishers and have a quick look and if I was worried they're going to fall into the friggin' linisher, I'd just go right back In a very gentle way.

Speaker 2: 16:57

Let's try something else, because I don't want to be responsible for them and grind their finger off in their career over there. Because it's a different skill. You're a little bit helped by scalpel work and that sort of thing develops fine motor skills. But orthotic making facilities and grinders and stuff they're fundamentally dangerous and if you don't have the aptitude for it then it's potentially a problem. But if you're going to do a lot of orthotic musculoskeletal type work, then I think you need to develop some of your skills there. I think the paradigm these days is they don't need to know how to make them, they need to know how to prescribe them. But I kind of figured out how to prescribe them, but we have to make them and see them not work and go. Well, I didn't buy them. Yeah, exactly, that's probably the script.

Speaker 1: 17:49

That's exactly it you learn how to prescribe from learning how to make and modify. I think there's a really important point, yeah, okay.

Speaker 2: 17:59

But I have encouraged my practitioners that have worked part of the team over the years to do as much of their own modification work as they want to do. But it has to look professional as well. It has to look lab quality. Quality, yes, because even if it's placebo and I'm sure it is placebo if a patient sees a good looking orthotic, they start expecting that something's going to work here. And if it looks like rubbish, well you're just behind the eight ball. And if it looks like you've used a 20 year old pair of scissors and it's as rough as guts and not very anatomically correct, then you probably should. Well, I won't. I won't let members of the team do that sort of stuff. Sure, that's good enough.

Speaker 1: 18:47

So what do you actually use then? As far as orthoses go in clinical practice, what are you using?

Speaker 2: 18:53

When you say or foces, do you make prescription, or across the board, Across the board. So I do a lot of direct padding and strapping on the foot in the usual there's this kind of thing that I'll do, and it's very old school padding and strapping often, and I think that's a skill that's perhaps diminished a little bit. I said a lot of orthotics a lot of orthotics that they're pretty good orthotic but they just lack some of the old British school of coroporty padding to suddenly turn an average orthotic into a really good orthotic.

Speaker 2: 19:22

I like to fix orthotics where I can, so a lot of padding and strapping, and then I have two or three different types of generic orthotics, probably the main one. I'm using superfeet, but I do use a few formers as well and they're my base if I'm going to then start to incorporate that padding or that posting onto them.

Speaker 1: 19:45

So modifying the preforms.

Speaker 2: 19:48

Yeah, I'll do a lot of that. I often give patients the choice between especially if it's forefoot pathology, you know you could go down the path of a prescription orthotics going to cost you this much. Padding is going to be identical on both. The padding is the critical component or you could put it on the generic. The generic won't last as long. When it's cheaper we can rebuild the prescription orthotic. You can't. That's no point rebuilding a generic. You just build another one when they need it.

Speaker 2: 20:18

And so I definitely look for generic orthotics where I can peel that cover back off the base so I can build padding in underneath. And so that's one of the things that I look at pretty carefully when I'm deciding, because I think between most of the generics there's not that big a difference between them. It's what you do with them. And then I did plenty of printed orthotics from a scanner. I have a high end scanner and pram, I use an iPad scanner in Mansfield. I don't think that makes any difference. I think it comes down to the script that you write yes, and then the ones I've got hold of that orthotic, and I prescribe my orthotics to be right first time, including the padding. But then you know, once it comes down to, if I'm modifying it, then it's to me and I'm doing that.

Speaker 1: 21:11

Yeah, yeah, so yeah, that's the whole thing, though I'm putting my hands on it really to make sure it is spot on.

Speaker 2: 21:20

Yeah.

Speaker 1: 21:21

For that 30 or 40 percent that need the modifications.

Speaker 2: 21:24

Correct, yeah, and then I'll be up at the farm. I've got a big shed, so I'm lucky enough to have an area where I can do some work on stuff and it's surprising, you know at a whole factory full of machinery once upon a time, and you don't need a lot to be able to do a lot of stuff.

Speaker 1: 21:47

Yeah.

Speaker 2: 21:48

If you've got manual skills to be able to do it Sure.

Speaker 1: 21:52

Yeah, but you sound like you are maintaining your sort of practical contact with the use of orthosis from, literally, this has been start to present. For you, like for many, this has been decades, yes Of keeping your hands in it.

Speaker 2: 22:10

Yeah.

Speaker 1: 22:10

Although, using some technology, it sounds like you're, you know you still got your still pushing the button on the machines.

Speaker 2: 22:17

Yeah, you know when I had important. Well, I had the lab years ago. I was heavily involved when we automated that and went to CAD-CAM manufacturing, so I was a very early adopter to a foot scanner rather than plaster casting, and so I've continued down that path. I think the 3D printed stuff that comes out is really nice from an aesthetics perspective. Yeah, it's good there's no doubt Plastic glides. That's harder to modify. You've got to be a little bit more skilled on it. Likes to melt rather than grind.

Speaker 1: 22:53

Yeah.

Speaker 2: 22:54

But that's like any material change You've got to figure it out.

Speaker 1: 22:58

And the materials have improved. Haven't I Significantly with the printing?

Speaker 2: 23:02

Yes, no doubt yeah, but again it's what you prescribe.

Speaker 1: 23:07

Yeah, that's really the key to it. That's it, matt. Thank you so much for your input. I really appreciate this. This has been an awesome series, hearing from different people and someone has experienced as you and with your diverse background it's a huge privilege to have you on the show, that's for sure and help us out with your tips. I really appreciate it.

Speaker 2: 23:30

Pleasure Joe, so happy to be involved, and once again, great job, you've done a good job.

Speaker 1: 23:35

Oh well, hopefully it helps a few people. But yeah, everyone shows, so hopefully we can get a bit of information out to everyone as well.

Speaker 2: 23:43

I'm putting me up. I'm sure you're helping more than a few mate.

Speaker 1: 23:48

Anyway, it's a bit of fun and speaking to people and catching up with people like yourself again too. Yeah, it's been a while Staying connected, which is great, but once again, thanks for your time, Thanks.

Speaker 2: 23:59

Emilian.

Speaker 1: 24:00

Thanks for having me Pleasure mate. See you soon. Thanks for tuning in. I hope you've enjoyed listening. Genie Orthoses are sponsoring these Orthoses in clinical practice sessions. More details can be found at thegenieau Links and details are in the show notes where you can follow and support this show. Thanks for listening and I'll speak to you all again soon.