Orthotics part 2

Please note: The following text cannot and should not replace advice from the patient's healthcare professional(s). Any person who experiences symptoms or feels that something may be wrong should seek individual, professional help for evaluation and/or treatment. This information is for guidance only and is not intended to provide individual medical advice.

Nicci is based at Westminster and Chelsea NHS Trust. She works for Opcare which is one of the biggest NHS providers of orthotic, prosthetics and wheelchair services. Opcare pride themselves on being innovative and at the forefront in patient care. Opcare’s mission statement is ‘Our mission is to provide professional services in a caring and informative manner. We seek to continually develop our understanding of the needs of each individual user and apply our knowledge to optimise their quality of life’.

There is a lot of misconception over orthotics and podiatry, the questions I hear the most consist of; who is better?, what’s the difference between podiatry and orthotics?,  and who should an EDS person see?

Let’s break everything down..

Podiatry:

Focuses on the treatment of disorders of the lower limb, normally below the knee. Treatments can comprise surgery and treatment of skin lesions e.g. ulcers and calluses. Podiatry can also prescribe insoles and adapting the patient’s own footwear with modifications.

Orthotics:

Although in some areas we overlap, orthotics focuses on the treatment of disorders of the whole musculoskeletal system. This means we use a wide range of custom-made externally applied devices such as custom-made insoles, custom footwear, splints etc which will prevent, correct and aid alignment to allow the patient to maintain function.

Orthotists and podiatrists often work in partnership to provide a comprehensive multi-disciplinary team (MDT) treatment solution for their patients.

INSOLES

For insoles, the assessment between podiatry and orthotics in most cases does not differ. However due to EDS being a multisystem condition which affects the whole body, you want to make sure that your insoles work together with any other orthotic devices you have.

The main criterion when seeing an orthotist or a podiatrist is what experience do they have with EDS.

Types of insoles

• Total contact insoles (TCI) – These are a type of a custom insole, specific to the patient’s needs
• Functional foot orthoses (FFO) – These are a type of a custom insole, specific to the patient’s needs
• Flat beds- These can be stock or custom for simple conditions
• Semi-custom – this is a stock arch support and is then adapted to meet the patient’s needs
• Stock- off the shelf item with no custom adaptions
• UCBL- custom-designed by the University California Berkley lab

All the above are made in various materials, with various adaptions dependant on the patient’s biomechanical needs, except stock insoles (off the shelf insoles) which are already premade specific to a condition.

Which is better custom vs semi-custom vs stock

None of these insoles is any less effective than the other. They are prescribed solely based on individual needs and the condition which requires support/offloading.

Please have a discussion with your clinician if you feel that your current insoles are not providing enough support as you can see there are multiple types of insoles and multiple types of adaptions. Just because you feel your current ones may not be helping you doesn’t mean there are no other types which might.

I do advise that if you have issues with your feet, always go to see an orthotist. Avoid buying insoles from retailers (e.g. from Amazon/Boots) as you may not be getting an insole which is functionally correct or beneficial to your needs.

How can I get the best out of my insoles:

• Please do not buy new shoes to take to your appointment. This is a waste of money – please wait until you have seen your orthotist/podiatrist for footwear advice before purchasing any footwear.
• Avoid buying any shoes until you have your insoles. Remember insoles are made for your feet, specific to your feet shape and alignment. Shop bought shoes are not customised to your feet. Some shoe types you simply can’t fit an insole in. The shoes should be brought to go around the insole not the insoles made to fit into specific footwear.
• Any shoes you buy must be able to work with the insoles to have the best effect on your alignment.
• If an insole is needed, then shoes are required to be sturdy and not over flexible. UGGs, memory foam Sketchers and ballet pumps are the best examples of footwear to avoid if you have been prescribed insoles.
• The best types of footwear are supportive shoes. Hoka and ASICS neutral are great trainers that work well with insoles.
• When wearing insoles avoid wearing shoes that are described as anti-pronators or under- pronators in the shops. These shoes are designed to provide extra support medially and under the arch. When an insole has been prescribed, the insoles will have a custom arch support made especially for you, therefore if an insole provides the support under your arch and the shoes are also providing support, it is very easy to push your biomechanics into the opposite of the function trying to be achieved. When purchasing a shoe always ask for a neutral heeled shoe.
• Avoid slip on shoes, when wearing an insole. Your feet need to be secure on the insoles – try laces, Velcro or a strap on shoe. This will allow your feet to be gripped on the shoe at every point in your gait.
• Sometimes you may need to go up half a shoe size – rarely this happens.
• Avoid high heel shoes as these stop your feet evenly distributing the pressure which can cause further biomechanical issues.
• Your insoles must be ‘broken in’. They are not only providing support but helping your alignment, which your body needs time to get used to. Sometimes it can take your body up to three months to get used to a new orthotic.
• As a rule of thumb when you first get your insoles, wear them only for one hour on the first day and then increase by one hour each day. For example: Day 1: 1 hr of wear, Day 2: 2 hrs of wear, Day 3: 3 hrs of wear. Continue this until you get to 6-8hrs and then wear all the time.
• For best use, put your insoles on in the morning and then take them off when you go to bed. The longer you wear them, the better the support you will have.
• Dependant on the type of insoles given, nearly all insoles require replacing or refurbishing each year. After all, you are wearing them for the most part of each day all year round. So, the material does condense down and requires replacing to allow the insoles to maintain giving you the optimum support required.
• Asking your orthotist/podiatrist to reduce the insoles in thickness/medially/laterally to fit in the shoes you would like them to fit in only compromises the insoles. Insoles are made with specific ground reaction force (GRF) to maintain corrective forces. Removing this reduces the effect and compromises your insoles and your treatment outcome.

Ankle bracing

Ankle bracing is used in the following conditions/symptoms

Concerns/issues

• Medial instability
• Lateral instability
• Dorsiflexion instability
• Plantarflexion instability
• Ligament laxity
• Sprains/tears
• Proprioception problems

All of the above types of ankle bracing can be custom-made or from stock. Due to custom ankle bracing being extensive with multiple adaptions, for the purpose of this article we will focus on stock ankle bracing only.

When I prescribe ankle bracing, the first thing I look at is the patient’s hand/finger movement and what (if any) type of manual dexterity they have.

As most of us with EDS, including myself, have issues with wrist and finger subluxations/dislocations/hyperextensions/stuck/clicking joints etc,  I always want to find the best type of support that is easy to donn and doff (get on and off). Velcro is an amazing invention however for some people it is very difficult to get on and off.

My go to devices with EDS patients are devices which have a BOA®. All these devices have a BOA system/PUSH dial system. Simply put, you push the button and twist; the device then tightens and then to take the device off you pull on the button out.

These devices reduce the amount of manual dexterity required. They are slim enough to fit within a shoe and provide adequate support. They are breathable and not hot, which is perfect for any heat intolerant patients

The Airsport brace works well for any fluctuation in swelling, as the back is open and can aid in accommodation. All devices are slipped on like a sock and are very lightweight and have padding to reduce the chances of any bruises.

Interesting facts about your feet:

• One quarter of the 206 bones in your body are found in your feet
• There are more than 250,000 sweat glands in each of your feet, when active they can produce 4 to 6 ounces in a day
• There are over 7,000 nerve endings in each foot.