Ep.34 Orthoses in Clinical Practice: Insightful Strategies with Matt Dilnott

Unlock the secrets of orthotic therapy with Matt Dilnot, a seasoned expert who's revolutionized his clinical methods. This episode promises a treasure trove of insights into the effective use of orthotics, ensuring you walk away with invaluable knowledge on patient treatment strategies. Matt's journey from a once frequent orthotic prescriber to a selective, evidence-based advocate showcases the profound transformation within our field. As we peel back the layers of historical overuse, you'll learn about the delicate balance between research and real-world application, and how it influences the way we mitigate lower limb conditions today.

Join us as we examine the dynamic world of orthotics, where we've transitioned from rigid to flexible devices, ensuring muscle function isn't compromised. The conversation with Matt brings to light pivotal research on the adverse effects of stiff orthotics on muscle atrophy, prompting a reevaluation of our approach to foot health. Hear about the growing acceptance of off-the-shelf orthotics in modern practice and their burgeoning role in patient care, marking a significant shift from skepticism to appreciation. This episode is more than a dialogue; it's an educational journey that will reshape your understanding of orthotic application and its lasting impact on patients' lives.

@simplythebestpodiatry

@jasonagosta

www.thegenie.au

Melbournefootclinic.com.au

@matthewdilnott

m.dilnott@melbournefootclinic.com.au

Transcript

Speaker 1: 0:05

Hi there and welcome back to simply the best panitri show, where we want to pass on simple tips to enhance your best panitri practice. I'm Jason Augusta, and thanks to all the guests so far and to you all for tuning in. Today I continue the orthosis in clinical practice episodes and I spoke to Matt Dilnot, who imparts great information and his approach to using orthosis. This is Matt Dilnot, so the idea was to get a few people to talk about their approach to the use of orthosis clinically and what are you using in your practice?

Speaker 2: 0:48

Over time, I feel like I see more and more examples in other professions and you go my god, there's no evidence for that and they're charging that much and we're worried about charging for a custom orthosis. I've become less concerned about the cost and I suppose it's probably because where I use them now I'm more confident in doing so and I'm using them less often, but I feel confident when I do use them, so that's probably where I come from.

Speaker 1: 1:18

So it's an interesting chat, isn't it because and I have said this a couple of times already about the best lecture I've heard on orthosis recently was from Arta from Footwork.

Speaker 2: 1:30

Oh yeah, maybe it's like the orthotic lab.

Speaker 1: 1:33

And there were hardly any podiatrists there. It wasn't like a practicing practicing podiatrists presenting, but it was something that everyone should have heard and it was amazing presentation as far as the depth of understanding of orthosis, how to use them, how they work, and I loved it and that's what this sort of inspired me to think about. Okay, what's everyone else doing? We can all learn from each other so much, just from being a little more vocal, and if this is a platform we can start on fantastic this. As I've said to you in the past, this show is the people show, but this is everyone's show, to come on and have everyone listen and speak as they please.

Speaker 2: 2:14

I think everyone's going to call it your show, though, jess.

Speaker 1: 2:17

I don't see it like that at all. I really don't, and it's more about a show for the profession, and I love it when people come on and speak, because I think it's a really, really good avenue that they can sort of open up and get started with speaking about it and particularly on this topic of orthosis, if we can take one step forward with that fantastic and especially for the younger practitioners as well.

Speaker 2: 2:43

I think perhaps one of the tricky parts for this is knowing where to start, because I think, as I've alluded to before in our previous conversation, you and I came from a different era and so therefore we had a different challenge in front of us at that particular stage, didn't we? Yeah, that challenge being can we learn root by mechanics and somehow deliver that in our practices? And we were looking at feet differently back then, weren't we? We were every foot that came in you're trying to size up, was it a valgus forefoot, or a various forefoot, or a supernatus, or a flexible forefoot, valgus or whatever.

Speaker 2: 3:25

And we just kept trying to guess as to what was the right thing to do, based purely on the static posture or whatever. Yes, and that would just lead you down a certain path for managing everything. And, as we've said in my past interviews, it's that we hadn't really embraced or understood, and still don't really I don't think we embrace it well enough in our but I to professionally strengthen the aspect. So therefore, we didn't have any other other avenues for managing foot problems and even shoes we've seen in our era, we've seen the fully cushioned shoes right through to the fully structured shoe, and every moment of it. We've believed that one thing is better than the other, and so we've seen everything.

Speaker 1: 4:19

Oh no. And then when the new things come along, it's confusing. And this is where we are, or at least we have been so confused with all those years and how to use them and what's right or wrong. Yeah, and that's you know, I think you know what you just alluded to.

Speaker 2: 4:35

There is that we did come out really confused about what to do, Bumbled our way along, and hopefully it's a little bit different these days, but I think it is that's what happened, yeah, and I think, and I think one of the parts of the history with that also meant that we then had students graduating who were then being told the evidence for custom orthosis is really poor and they were scared as anything to prescribe an orthotic.

Speaker 2: 5:03

And I think and I think you know there is some reasonable reasons for saying that to students, because you could argue that podiatry is probably in a position where it may perhaps, as over prescribing custom orthosis. We need to rein it in a little bit and we're going to try and find that happy balance between the two and that's and that hasn't been an easy thing, as we've discussed, because we've had to wait for the research to evolve and develop and then we've got to take that research and know how to apply it and it takes a while for us to reconcile all of those different aspects of route biomechanics and how do I use this for this particular type of condition and that's, that's. That's challenging when you don't have a recipe book, you know, but so just on that note about evidence, though I mean if we evidence is there the evidence is there, but there's so much inconclusive literature.

Speaker 2: 6:01

Yeah, but I think I think I tend to focus on the things that have been shown relatively repetitively I suppose. So the things that the common themes, that that have, for the last probably 30 years, themes have emerged and I feel pretty comfortable with those themes. Now I think I particularly focus on the decreased velocity aspect of of orthotics. The ability of an orthotic to decrease the velocity of movement and therefore the loading of tissues is one of my probably my favorite, one of my favorite ones. We know that orthoses do decrease the range of pronation in most circumstances and again, this is a tricky thing to state because we want, we want a one size fits all statement for every single foot, and so it's like saying all shoes, do this to a foot and you go. Well, depends on the shoe, you know. It depends on the custom orthotic and the way the orthotics prescribed is going to that, plus the foot itself, is going to change the end result.

Speaker 2: 7:13

So we've seen those, those studies in the past where they said we use an orthotic and no one changed and he said well, what was the orthotic that you used or what was the type of foot that you actually applied it to? So we've got all these. And then someone says, oh look, orthotics do nothing. But do you think that the study methodology wasn't particularly good? And so when you start to filter out the rubbish and you start to look towards the good studies, I think you do see that consistent thing of decreased velocity, decreased range of pronation in certain foot types. You get decreased internal tibia rotation in certain foot types, you get improved shock absorbency, you get decreased stress on certain foot and ankle musculature. So there's, we get these repetitive patterns happening all the time and I feel pretty comfortable with that.

Speaker 1: 7:57

I think the wrong thing, though, is to grasp those things and assume that is so applicable to everybody, and I must, you know, try to try to slow, motion down or change the range in everybody, for every single problem. I think that's where people falling into trouble, absolutely Assuming that everyone needs this.

Speaker 2: 8:20

Everyone needs it Exactly.

Speaker 1: 8:22

With the same, you know, style of device or level of support or whatever. I think that's a really big problem because it is quite confusing some of the literature there's heaps of junk Once you decipher through it. Sure there might be things that come in consistently, but there's a lot that's actually been quite poor and inconfusing.

Speaker 2: 8:41

Absolutely, and I think, and I think ultimately it comes down to where experts in load management, and so, with all of your biomechanical skills, you need to look at what are the tissues I'm trying to unload. It's the tissue stress model. What are the tissues I'm trying to unload? What's going to be the best orthotic to try and unload that, based on my the best of my knowledge? And what other things can I do around that orthotic? Don't put all of your eggs in the basket of the orthotic. It's all of the other stuff we've spoken about before. It's the changing loading patterns, it's the change in running training drills or whatever it may be that's going to assist it. So you're not Just relying on that orthotic to do the work for you. Um, yeah.

Speaker 1: 9:23

And that's been a big shit for us. Sorry, I was just going to say Gus McSwain, who was on the show as well. He just mentioned exactly the same approach as well, the same ideology. Can I ask you, clinically, what are you? I mean, you've just touched on this, but in simple terms, what is your sort of ideology or sort of philosophy of the use of devices, like when and why and what are you using?

Speaker 2: 9:52

Yeah, sure, yeah, look, basically I would say that, first of all, then, my use of custom orthoses has probably dropped from year to year to year. Um, so, I think, because my load management strategies have improved. So, therefore, patient comes in with heel pain, I can look towards walking modification, shoe modification, stretching modification, strengthening modification, all these other aspects. And whereas at the very beginning, planofasciitis oh, we need to support the arch wall to reduce the pressure on the planofascio Now it's like, oh, that's way down the track for me and I've found that over time, it's just wow, I can manage planofasciitis without an orthotic. Or, and it's not to say, I never use an orthotic for planofasciitis. Don't get me wrong, there are still situations where I'll use it, but it's not straight to a custom orthotic for the planofasciitis, and the same with shin splints, same for knee pains and all sorts of other things. Yeah, it's the one part of the whole like you know, treatment plan as we've mentioned Exactly.

Speaker 2: 10:57

That's right and I think that's another evolution of our thinking is that before it was very early on in the plan and now it's it's a bit further down the track. So I would fully evaluate a patient as far as at the beginning of what has what has changed I've spoken about that before what has changed and therefore what's led to this particular event occurring in their life, and then modifying some of those changes if we can, I would. If I do reach that point where I do consider an orthotic to be useful, it's a reasonable chance. It's going to be a relatively minimal intervention like and over the counter device is going to be a softy sort of thing, sort of minimal stuff, and it's a bit of a test of the water. It's a test of the water for the patients. It's a cheap intervention Generation do you think so?

Speaker 1: 11:56

we bumbled our way through, came out the other end, and this is where we're at like approaching this really conservatively.

Speaker 2: 12:04

I don't think it's conservative. I think it's because we actually, we actually probably have reasonable faith in the off the shelf device now.

Speaker 1: 12:14

I don't.

Speaker 2: 12:15

I don't think I look at the off the shelf devices being a completely inferior product. I often say to patients if this is good enough for what you need, it's good enough. It's not going to. If you're pain free with this cheap off the shelf device, then you can't be more pain free. Yeah, custom orthotic so. So if the patient has that off the shelf device has a successful outcome and that wears out in three months and then their pain comes back and clearly they're showing that repetition that once the device is not working anymore, yeah Well, look, let's look towards a more permanent situation here and a customer orthotic is going to be more useful.

Speaker 2: 12:53

And we all know the thing with fitting into shoes without the shop devices quite often bulkier or whatever, and so therefore you can get some pretty slim. You know nylon devices and and carbon fiber devices and so forth, so they fit into shoes and if someone's going to be wearing those things for a long time, that's that's going to be more appropriate. So I think we we filter out our patients just more effectively these days Once we go through these processes of load management and strengthening and stretching and so forth, very few of them get to that end result of the customer orthotic now in comparison to what it was, yeah, so so what are you actually using?

Speaker 2: 13:31

The actual brand names of things we're talking brand names. Brand names this material whatever I have to say, it would be.

Speaker 1: 13:39

People want to know yeah.

Speaker 2: 13:41

Yeah, exactly. Look, I tend to use Slimflex softies a fair bit for just like a gentle bit of arch support for someone, especially if they're older. It's not going to irritate anything, it's just going to create a nice sort of bit of stability for the foot and it's a bit of a test the water sort of thing. Stepping up from that might go to exactly the same thing as Slimflex device with a firmer material. It's a medium density, gives a little bit more life. Someone is younger, it's going to work for a bit longer. And then I move up to a form thotic. And it's not always this case. Sometimes I make it directly to a form thotic and I tend to use the dual density ones. And I like the full length bits because I can add pads to them and just add EVA bits and pieces to them.

Speaker 2: 14:32

You can wedge them in the rear foot, you can wedge them in the mid foot, you can do all sorts of stuff with them. So it's a nice little platform.

Speaker 2: 14:39

It's a base for you, Absolutely exactly, and then from there it's going to be the custom orthotic for certain patients, and some of those might be because you want to have that more instantiate which you just can't get with other things, or it might be because you want to have more rear foot support or whatever it may be that you can't get. So that tends to be my sort of philosophy and approach.

Speaker 1: 15:05

Polypropylene or the nylon devices for your customs. What would you?

Speaker 2: 15:11

sort of would you? Just vary it up a bit, depending on the situation I would say, as a general rule of thumb, I would almost always go for carbon or that sort of laminate stuff. So it's plastic, carbon or nylon devices basically.

Speaker 1: 15:32

Those are my sort of polycarbons and polycarbons. Polycarbons and the nylons are those of the two that I would go to. Yeah, so it's interesting, isn't it? Thinking about where we're at over time, where we started and the little journey over 30, 35 years and how that approach has become maybe a little well, not focused, but a little more conservative in the use of orthosis in the preforms being a lot more readily used in our rooms.

Speaker 2: 16:05

But I think, if you reflect on where we started from I think there was we looked down our noses on prefabs and first of all, there wasn't a lot of prefabs when we first started, and then and we were so sold on the whole need for a custom orthotic when we graduated- the only thing, it was the only way to go.

Speaker 2: 16:23

Yeah exactly so you wouldn't entertain an off-the-shelf device. And then, I think, once the tissue load model, tissue stress model started to come along, we started to then believe, actually we could probably just reduce loads by using an off-the-shelf device, and I think we had then had comfort in what we were doing. And I think, as the root model started to disappear and we didn't, we'd realized hey, you basically reduce it. Matter of pronation or whatever it may, supination, we can do this with off-the-shelf device pretty well.

Speaker 1: 16:56

Yes.

Speaker 2: 16:57

You know, and I think as we've gone on we also realized you can do simple things that they've just found, that you know, just doing a rear foot post without the orthotic is a pretty good job of controlling internal rotation of the tibia. So you don't need the whole box and dice of arch support for some people. You just need to use some sort of valgus wedging like they've used with knee pain, for example. You know medial knee pain. They've just used valgus wedging in the forefoot.

Speaker 1: 17:26

Yeah.

Speaker 2: 17:27

You don't need the whole shebang for that. So I think there's some good enough science out there now to say that just the old-fashioned custom orthotic is not the beeline end all that it used to be.

Speaker 1: 17:45

I think what you're saying and reiterating from what I've said earlier is we know that small changes have a massive effect. You only need to intervene mildly. So if you think about walking thousands of steps per day, one and a half times your body weight, then think about running Absolutely. What is it? A thousand steps per kilometer?

Speaker 2: 18:08

Yeah, Something like that.

Speaker 1: 18:10

So go and run 10K. There's your 10,000 steps At two to three times your body weight. You only need to change things. The smallest degree, yeah, and conversely, you can also do too much, ever so slightly to get a negative effect. But if you intervene so conservatively, my thought is, with the loads being so high and repetitive, that has to have an effect on your low limb.

Speaker 2: 18:37

Oh, absolutely.

Speaker 1: 18:38

I think that's where we're at. And if you think about think back to when we started, when you know the molded polypropylene, you know the big six, or seven mill.

Speaker 2: 18:46

It was like converted.

Speaker 1: 18:48

Six or seven mill rigid poly device was the only way to go and what we did know from some of the evidence that did increased impact through the load.

Speaker 2: 18:56

Exactly.

Speaker 1: 18:57

We know that they're still being used readily, and it was like, oh my God, we're so far away from that now, thankfully, and I think that's the one of the points you're making here.

Speaker 1: 19:10

I also bring in and link this up to episode seven of this series with Anja Vereena Belling, with John Osborne interviewed. So episode seven she's a biomechanist and works with Ben I Nigg's lab in Calgary and she was very, very clear about it just doesn't suit us to have a rigid, locked foot. We need to maintain movement and that is crucial for a, obviously, adaption impact. All sorts of things that's worth going back and having a listen to as well.

Speaker 2: 19:48

Yeah, I think so, and it was a really good paper published and people don't seem to have talked about this much. This is by a fellow Poe of Huppas in clinical biomechanics in 2020. He did an interesting study. It gave people custom authorities for 12 weeks and looked at the effect on the size of the muscles. He looked at particularly abductoralysis and flicturgisodestroin brevis and that particular study. I think the end result was something like abductoralysis decreased in size by 17% and flicturgisodestroin brevis by 10% In 12 weeks.

Speaker 1: 20:29

Of using devices.

Speaker 2: 20:30

Of using a custom orthotic. Now I think the orthotics that they were prescribing were actually quite high arch and I think the higher arch, the more stiff they are, you actually end up getting more atrophy of tissues. You're splitting the foot, Splinting the foot, that's right. And there was another paper also it was MacLinton in JOSBT. He showed that people who had heel pain who wore orthoses had weaker toe strength. So essentially that's a complete sensor. It does make sense, it doesn't like.

Speaker 2: 21:09

Yeah, that's right. So, and I think, going back to your previous point about stiff orthotics, one of the things I think I noticed very early on was that when people were, say, landing with a medial heel strike which is probably not a great place to strike the ground on the medial side of your cow when you put them into a rigid device, it actually caused them to start striking laterally. And you may have observed this and we all just thought it was all just because of, you know, reducing pronation, whatever, but I strongly believe that when you splint the foot, it has to invert the foot more before it strikes the ground to try and regain some of the shock absorbency. So it's actually inverting the foot in response to that stiffness that it's experiencing, to say, hey, I need to have space for shock absorbency, so I'm going to strike the ground more laterally on the heel, so I've got that room, so you start to fire.

Speaker 1: 22:09

I've got room to move centrally. That's right. You're going to go across the midline?

Speaker 2: 22:13

Yeah, I'll get you yes, and so you start to fire tid post more early on. So you have to invert the foot more. And I think this is where Luke Kelly's stuff comes into it, Because he was showing that orthotics increase muscle activity. I think it was particularly in extrinsics because they have to adapt to that increased stiffness by adjusting foot mechanics prior to heel strike to retain that shock absorbency aspect. But when it comes to the intrinsic, when you splint the foot you're actually taking load away from those intrinsics and they will atrophy. And I have seen those feet who were wearing orthotics for 20, 30 years with really those old fashioned stiff, high arch and they're completely dependent on them. They said I tried to carry that my orthotics for two days but feet killed me Because the muscles of atrophy, like that they couldn't cope Exactly.

Speaker 2: 23:05

They couldn't cope. And you can see these patients who've got their abductor. Helicis has completely disappeared. It's just nothing. So, and I think again that probably gives us support for having a device that's more flexible because it helps to maintain some load on those tissues. It's still reducing that velocity of movement but it's actually not taking away all the load on those tissues, so you're going to maintain your muscle bulk.

Speaker 1: 23:28

That's it Exactly. And well, you've gone through that in the last few episodes as well. As far as strengthening and how important that is, I get that. It's so good. I've been doing my strengthening too, matt. Trust me, I think it's really. I'd love that overview of the journey, of starting where we were and then where we are now and the philosophies behind it in maintaining movement, really is what you're saying we need to maintain movement, to maintain muscular control. That's crucial.

Speaker 2: 24:01

And it's funny actually you mentioned that because I remember when I first met Tom this popular show and he said yes, but I trust you seem to be trying to make. Stop all of the joints from moving. As chiropractors we're always trying to make joints move more.

Speaker 1: 24:18

Yeah Well, that's exactly what I was saying about that episode seven. That's all about maintaining movement. We don't want to lock anything.

Speaker 2: 24:25

No, exactly that's right.

Speaker 1: 24:27

Yep, yep. So over time, great differences in approach. Hey, I really appreciate your time coming back on. It's great and once again, I really appreciate your input. Always amazing depth of knowledge, matt, I've learned that much from you. Oh, my God, my strengthening.

Speaker 2: 24:43

Go to the on. Jason, you know that strength.

Speaker 1: 24:45

I have to say this, why people are listening. The strengthening is absolutely amazing and I didn't realize how weak I was when I had my toes extended doing that ballet All right, yeah, the lame maneuver, the lame maneuver.

Speaker 2: 24:56

But.

Speaker 1: 24:57

I'm sitting in the chair now with my toes extended underneath me, and there's even an effect I can feel when I push my toes down into the ground.

Speaker 2: 25:04

There you go.

Speaker 1: 25:04

Standing there and leaning forward, pushing my toes into the ground with my heel raised. It's so easy to do, consistently it is. It's so much a winner and such a big thing. So I really appreciate you passing it on to me and everybody else. Hey, the Billy Idol of Padatri Love you coming on the show.

Speaker 2: 25:22

Thanks, jason, good on you, thank you, thank you, thanks. Thanks, thanks, ian.

Speaker 1: 25:27

Thanks for tuning in to Simply the Best Padatri. I hope this episode was helpful and informative. More details in the show notes. We can follow and support this show. You can also follow us on Instagram at Simply the Best Padatri. These orthoses episodes are sponsored by Genie Orthoses. More information can be found on the web page TheGenie T-H-E-G-E-N-I-E dot a-u. Thegenie dot a-u. Thanks for listening and I'll be with you again soon.