As we go through our daily routines and activities, we don't often think about what's going on in our feet and legs. But with every step we take, more than 26 foot and ankle bones and 208 muscles are being used. The functioning of these bones and muscles impacts the joints and structures above them, so improper functioning of the feet caused by misalignment and biomechanical problems can result in painful and chronic afflictions of the knees, hips, and lower back, not to mention the feet themselves.

Many people suffer from such pains and strains, but how many are aware that the problem can often be solved by proper attention to their lower extremities? That's where the Midwest Physical Therapy & Sports Center (MWPT) comes in. A full-service sports-medicine-based facility treating just about every possible orthopedic injury from tendinitis to postoperative ACL reconstruction and total knee replacement, the clinic devotes about 10% of its workload to treatment of the feet. And in those cases where evaluation indicates the need for an orthotic, MWPT provides a benefit to its patients that is not widely available: same-day service.

Prescription and Design Groundwork

The orthotic is being ground to a shape that will place the foot in its best biomechanical position. The orthotic can be ground to hold the arch fairly rigid or to allow for movement, depending on what is needed. The orthotic can also be shaped to bring the ground up to the foot ( example: for a patient with a forefoot varus or valgus).

Rob Kobza, PT, OCS, CSCS, and manager of one of MWPT's facilities in the Lincoln, Neb, area, explains that, "We brought foot orthotics in-house to decrease the turnaround time. We can deliver a finished product to the patient the same day—a process that might take 3 to 4 weeks if sent out to a lab."

Kobza works 10-hour days at the Pine Lake branch in Lincoln. The busy clinics—two in Lincoln and one in nearby Ashland—are staffed by nine PTs and three PTAs, and give 400 to 500 treatments per week (all inclusive).

The clinic has been in operation for 11 years, but only in the past 2 years has foot-orthotic prescription and fabrication been offered in-house. As Kobza says, "The majority of clinics working in foot orthotics still send out slipper casts for fabrication at laboratories." So why has MWPT moved the entire operation in-house? The main reason, once again, is turnaround time. Obviously, the patient benefits from gaining relief sooner. But also, because of the subtle adjustments that must often be made in making the supportive device, "orthotics," Kobza says, "is as much an art form as a science. By doing it in-house, you're able to control all aspects of the process."

Physicians, podiatrists, and athletic trainers refer the majority of MWPT's foot patients to the clinic. Foot problems are common and can involve a wide variety of ailments including shin splints, Achilles tendinitis, plantar fasciitis, stress fractures, and a multiplicity of biomechanical issues. Evaluation is one area that is showing significant improvement. "Today," Kobza emphasizes, "therapists are getting to be very good at biomechanical, structural, and gait evaluation." This is especially important, he says, when it comes to fabrication. "There's a lot of fine-tuning, for instance, to get just the right amount of posting, where wedging is tilted one way or the other to bring the foot into correct alignment with the ground during walking."

While there may be subtleties involved in orthotics design and fabrication, the technology is relatively simple. The orthotic is made from moldable thermo plastic, which is covered by poron (a foam-like substance), which is in turn covered by protective vinyl. The equipment used in the process is fairly basic—a convection oven to heat and soften the moldable plastic, a motorized grinder to shape the cork, and a smaller, handheld grinder called a dremel for detail work. The most specialized piece of equipment is a platform that the patient stands on that has soft foam foot pads to capture the patient's arch. Prescription footwear company Fastech, Troy, Mich, manufactures this item as well as all associated materials such as insoles, cork, top covers, and metatarsal pads, and is the only supplier that Kobza uses.

It's relatively inexpensive to get started in foot orthotics. "It's not that high-tech," Kobza says. "Three or four thousand dollars will buy the materials you need."

Kobza describes the foot-orthotic process: "It starts with the evaluation, which tells us whether an orthotic will help. We look at the foot biomechanically as well as structurally. We look at the strength and flexibility of various body parts and do a thorough gait evaluation." Kobza adds that he also looks at the patient's shoewear and the wear patterns on their shoes.

If the evaluation determines that an orthotic would be helpful, Kobza next decides what type of orthotic would be appropriate. "Do I want a softer or firmer orthotic? Usually, this depends on whether the patient has a pronatory (mobile) foot or supinatory (rigid) foot. I also decide if posting is needed to compensate for a structural problem such as forefoot varus or rearfoot varus. There are other things as well that I could do to the orthotic, but degree of firmness and posting are the main ones."

Next is sizing and fitting of the foot with the thermoplastic insole. First, the insole must be made pliable. "I place the thermoplastic insoles in a convection oven and heat them," he says. "Then, I'll have the patient stand on the soft foam platform with the foot placed in a subtalar neutral position while I hold the insole to the bottom of the foot."

After about a minute to cool, the insole is ready for further fabrication. "I will then add a material to the bottom of the insole, usually either cork or ethyl vinyl acetate (EVA). This material will help to support the arch, making the orthotic either more rigid or more shock-absorbing."

Final contouring is achieved with the grinder and dremel. "I'll shape the cork or EVA using a grinder, and this is when the posting in the rearfoot or forefoot is added. If the orthotic needs a deep heel seat or metatarsal pad, I'll add that at this point," he adds. A deep heel seat or metartarsal pad will add 1 to 2 hours to the fabrication time.

A Welcome Relief

A patient stands on a heated thermoplastic insole while the subtalar joint is being held in a neutral position, and waits for the insole to cool. Once it is cool, it will be in the shape of the patient's arch.

Upon wearing the orthotic, relief usually comes quickly, Kobza says. He cites a case of a woman who complained of pain in her calves after walking any appreciable distance. His evaluation revealed a forefoot valgus that caused an angling downward of the inside of the forefoot. "This caused a lateral bounce to the outside of the foot, eccentrically loading the peroneals (sides of the calves), causing the calves to become tight and sore," he explains. Kobza designed an orthotic with a lateral forefoot post that brought the ground up to the lateral aspect of her foot. "Relief was almost instantaneous," Kobza reports.

One of the most common foot ailments treated at the clinic is plantar fasciitis. Formerly known as "Policeman's Heel," this painful inflammatory condition—usually affecting the calcaneus (heel) but sometimes found throughout the soft-tissue structure on the bottom of the foot—is often caused by abnormal pronation. Kobza estimates that one third to one half of orthotic patients have collapsing of the arch that can result in this common ailment that generally afflicts sufferers first thing in the morning and whenever they get up to walk after sitting for a while. Interestingly, however, plantar fasciitis can also be caused by a supinatory, high-arched foot, and the symptoms in either case—of the low arch or the high arch—can be very similar. "So we have to decide what's causing the plantar fasciitis—is it the low, collapsing arch or the high, rigid arch?—and design the orthotic accordingly. The biomechanical evaluation is very important in giving the patient the correct orthotic for their particular condition."

The evaluation process is generally covered by the patient's insurance, but the cost of the orthotic is not. Mindful of this, MWPT charges $244 per pair for the orthotic, which is "relatively low compared to the $300 to $400 often charged by others," Kobza says. Sometimes the orthotic may be covered if it's directly related to a covered

illness, such as diabetes. "But we don't handle diabetic foot-related problems. It's a complex medical problem that may involve wounds and other issues that are not encompassed here at the clinic. Also, the type of orthotic typically needed is softer than we make here."

Foot orthotics come in three grades of firmness: soft, semirigid, and rigid. "We specialize in the semirigid," Kobza says, "because they can be adjusted in either direction for greater flexibility."

As a manager, Kobza also attends to marketing, and is convinced that when it comes to winning business, a direct, personal approach is the most effective. "We do mass mailings to area physicians, schools, sports teams, and so on, but what works best is direct face-time with doctors. We have luncheons with doctors and talks at running clinics where we bring along our staff and everybody gets to relate personally. That's the best way for us to go as far as marketing is concerned."

Kobza believes that bringing foot orthotics in-house is a significant and productive change made possible by the improvement in therapists' evaluation techniques. "That's really our area of expertise—the biomechanical, structural, and gait evaluations," he explains. "Since we do a pretty good job at that, it's just been natural to make the orthotics in-house. I think you'll see more of that kind of transformation—it's just starting, but you'll see more of that as therapists see that niche growing."

Another development that Kobza would like to see in the future is the utilization by clinics of some of the high-tech apparatus currently used exclusively by research labs, podiatrists, and orthotists. Such devices as foot-pressure sensors that give computerized readings of contact-pressure distribution and timing can be beneficial for diagnosing ailments likes metatarsalgia (pain in the toe area). The expense of these items can be prohibitive for most clinics, however, and Kobza hopes that more economical versions will appear in the future.

Alan Ruskin is a staff writer for Physical Therapy Products. For more information, contact