If you are interested in prescribing more orthotics, this article will help you achieve your goal.
The Right Mindset
A good mindset to have is the idea of acquired deformity. If it is present, then to stop its progression the patient will need prescription orthotics. In other words, if a biomechanical imbalance is present, then orthotics should be a consideration. By having this thought process in place, this alone will begin to enable you to prescribe orthotics more readily. Surprisingly, a lot of practitioners hesitate to recommend orthotics on an initial visit. They may want to explore other treatment modalities. Or perhaps feel that they don’t want to encumber patients with the costs of orthotics.
It’s interesting to note that if a patient presents to a foot specialist with orthotics they have had in the past that have failed, the practitioner will often forget about the whole idea of orthotics. The fact remains that these cases need not represent an obstacle, but rather, an opportunity.
Let’s begin with considering your initial visit, when a patient is coming to your office for the first time. When it comes to painful foot problems, there is a good chance that the cause will be biomechanical in nature (excluding ingrown nails, foreign bodies or other dermatological, vascular, or neurological entities, etc.). Heel and arch pain, bunions, neuromas, callouses, and generalized foot discomfort are primarily associated with either a pronated foot, a rigid high arched foot, or a flexible pas cavus foot type. The same is true for several other foot complaints as well as some lower leg, knee or even back complaints.
A patient may present with a complaint of a painful callous, sub 2nd metatarsal head. You would then debride it and perhaps provide some accommodation or padding. You may even have a look at their shoes and offer some advice regarding stretching, taping, massage, etc. Most practitioners would suggest that the patient return to office for a follow up visit either at a pre-appointed time or when the callous begins to bother the patient. The key in these cases is to evaluate the patient’s biomechanics. Even though they are simply complaining of a callous, they should be advised that the cause of the problem is the way in which they are walking. Likely, in this case it is due to shearing forces during pronation.
Why not suggest to the patient on that visit that the cause of their problem is biomechanical? You can go into further depth with your explanation of this fact. The patient should understand that orthotics are indicated and why. Yet, many practitioners avoid prescribing orthotics on an initial visit. Why is that? It should be second nature to you, if orthotics are indicated.
Often the patient is told to return to the office for a follow up where they will be re-assessed. The practitioner may feel it is better to wait and see how things go. Perhaps they want the patient to get used to seeing them as a practitioner before recommending orthotics. Perhaps they are not confident about prescribing orthotics on the first visit, and don’t want to seem pushy. But, if orthotics are indicated, it is a disservice to the patient not to recommend them.
If a patient has a biomechanical foot imbalance on an initial visit, it’s fine to use all of the treatment modalities available. Patients usually want to know why they are having foot problems. Explain to them the cause of the problem, and that you plan to treat the cause, and not just alleviate symptoms. Emphasize that orthotics will be the best way to correct the source of the problem. Explain to them the process. You will take a cast of their feet in a corrected non-weight bearing position, and along with your biomechanical exam, send it to a specialized lab for fabrication of orthotic devices. You may want to add that the only disadvantage is the expense, but that many insurance companies do cover some or all of the cost.
In fact, you should be set up in your office to do casting right on the spot. The patient is coming to you for help, so don’t wait and see how it goes before prescribing orthotics. Your office can flow smoothly and patients won’t be waiting as a result. You may be pleasantly surprised to learn that patients appreciate your directness and are willing to follow your advice and recommendations.
If they need orthotics, then prescribe them! Why wait for another visit. They may go elsewhere for another opinion, or worse, wind up getting orthotics at a retailer that won’t help their problem. Being direct with your recommendation is key, your training will back you on this. Tell them that this is what needs to be done to correct the foot problem. Everything else is just ‘window dressing”, basically skirting the issue. The pads and tape will help, but patients will appreciate the fact that you want to get to the cause of their symptoms and not just the symptoms alone. Otherwise their relief may be short lived and then the pain recurs, your patient will think you didn’t do enough to help them.
Knowing that a patient has extended health coverage will of course make things easier for them to go along with your recommendations. But if they don’t, you cannot assume that they will not be able to or willing to afford orthotics. Feet are important and they need to have comfort and mobility. Their health takes priority over a lot of other expenses. Of course it helps if you can offer extended payment plans and various methods of payments to help. Some practitioners may reduce their fees as a courtesy to patients who truly cannot afford orthotics. If you can bend a little for the patient, your willingness to do so will go a long way in the long run.
Success with orthotics and an increased volume is somewhat dependent on your mindset. Don’t put off telling them what you know will help them. There’s a good chance that patients have already heard of orthotics and some may even suspect they need them. If the concept is new, it is up to you to make things clear. They will make your patients more comfortable and happier. Perhaps you have seen it already. Patients get their orthotics and try them in their shoes for the first time. Sometimes, they say the pain is instantly gone! It doesn’t always work out this way, but it happens often enough. Often enough that you should be confident to go ahead and cast a patient for orthotics on their initial visit, if they need them. You’ll both be better off for it.