The Annual Orthotic Re-examination

C ustom-fitted orthot­ics have proven to be very helpful for many chi­ropractic patients. How­ever, over time, they can lose their value or even be­come detrimental if they are not regularly checked and updated. Because they arc exposed to variable environ­mental and biomechanical stresses, the life spans of orthotics differ significantly from patient to patient. Obviously, the orthotics of a runner who puts in 80 miles a week arc likely to have a different lifespan than those of a sedentary grandmother. Also, body chemistry and sweat produc­tion can reduce the supportive qualities of some orthotics, over time. And some patients really need to have new models or types of orthotics, but often don't know what is available. These arc all good reasons to perform a re-assessment of the orthotics you have recom­mended. The frequency of these orthotie re-exams will vary according to patient needs, but should definitely not exceed a year. Experience dictates that a system to schedule an annual orthotic re-examination works best for most patients. Establishing Office Procedures Some type of tracking system is neces­sary, since a year goes by rapidly, and we often can't remember exactly who re­ceived orthotics and when. Traditionally, the doctor's assistant scts-up a "tickler file" composed of file cards with the patient's name and the date they received their orthotics. Each card is filed in the appropriate month, and then each month would be checked to see who had been fitted with orthotics in previous years. With computers, many patient-tracking programs can now perform this function. Some orthotic labs will automatically pro­vide monthly lists of patients who need rc-chccks; this can be a tremendous help to the office staff. Notification of patients can be done with reminder letters, postcards, or a tele- phone call. It's usually a good idea to use all three, since patients often appre­ciate the personal contact, and some respond more to phone calls than to mailers. They are thrilled to know that someone is keeping track of their health needs. Most doctors of chiropractic offer a free orthotic "check-out" with a (regularly-priced) spi­nal adjustment. A more mo- tivating approach is to offer a free main­tenance adjustment anytime during the weeks of patients' birthdays. This pro­vides an opportunity to check the status of their orthotics, as well as their nutri­tion and exercises, at the same time. Many patients will express an interest in a new or different pair of orthotics, or possibly some custom-fitted shoes or sandals when they see samples and posters. Why Reassessment? Certainly, if the orthotics arc not ad­dressing a patient's musculoskeletal prob­lems, they need to be re-evaluated. Some­times they are not the correct style for the shoes being worn. Occasionally, they need to be modified or further custom­ized. And sometimes the patient's needs have changed, as he or she has added new activities or switched employment. Once in a while, there is a wearing down of the orthotic materials, to the point where the previous support and control arc absent. In these cases, modification of the current orthotics, or providing a newer or more suitable style of orthotic, is needed. In many cases, the orthotics have been functioning well, but a re-assessment still finds a need for additional orthotics. In fact, most patients who are happy with their orthotics arc interested in being fit­ted with additional pairs for their other shoes, or they would like a pair of cus­tom-fitted shoes or sandals, with an orthotic included. Some patients have become interested in the subtle health benefits of magnetic therapy, and are in­terested in purchasing orthotics that con­tain magnets. With some professional orthotics labs, if the new orthotics are being ordered within a year or two, there is usually no need to recast the patient. This allows the doctor to discount these repeat purchases, providing further incen­tive to the patients. The Re-exam—What to Look For First, look at the patient's shoes. Iden­tify any unusual wear patterns, especially if the shoes have been purchased since the patient received the orthotics. Check the fit of the shoes very carefully, because many orthotic problems are actually shoe-fit problems. This is particularly true in women, who frequently force their feet into shoes that are too small, and don't update their shoe size as they age.1 Children's orthotics should be re-as­sessed more frequently (about every six months), because their feet are growing and their shoe sizes can change rapidly.2"1 Also, obese children should be given special attention, as excess body mass appears to have a significant effect on their foot structures.5 Next, examine the feet for calluses, subluxations, and any tender or symp­tomatic areas. These arc all indicators of persisting biomechanical problems, which are not being adequately addressed by the orthotics. Also, check for sweating or dampness (hyperhidrosis); orthotics using newer materials that wick away moisture may be indicated. Then, remove the orthotics and inspect them carefully. Is there any noticeable pattern of excessive wearing of any of the materials? Are all of the original char­acteristics (shock absorption, flexibility, arch support) still present? Is there any evidence of damage from moisture or from use? When any of these factors is present, new orthotics (and possibly a different style) are indicated. Finally, evaluate the effect of the orthot­ics on the spine and pelvis. Have the spinal symptoms and recurrent subluxations been eliminated or controlled as expected? Is there still any indication of more spinal stress during standing and walking? Is relaxed gait performed with smoothness and coordination? Do other tests during weight bearing (such as manual muscle testing) demonstrate good function? If not, consideration of modifi- cation of the current orthotics or use of a different style is appropriate. Conclusion An annual re-examination of patients' orthotics provides an opportunity to as­sess the response and the functionality of the orthotics. It also provides an op­portunity to re-assess the needs of pa­tients, and to offer additional styles of orthotics (i.e., for their sport shoes), and to suggest the use of custom-fitted shoes and sandals. Patients appreciate doctors who follow up; this demonstrates a level of caring that is not commonly found in busy health professionals today. By de­veloping some simple office procedures for an annual orthotics re-examination, doctors of chiropractic can provide a more comprehensive service for many of their patients. Dr. John J. Danchik is the seventh in­ductee to the American Chiropractic As­sociation Sports Hall of Fame. He is the current chairperson of the United States Olympic Committee .V Chiropractic Selec­tion Program. He lectures extensively in the United States and abroad on current trends in sports chiropractic and reha­bilitation. Dr. Danchik is an associate editor of the Journal of the Neuromusculoskeletal System and the Journal of Chiropractic Sports Injuries and Rehabilitation. He has been in private practice in Massachusetts for 23 years. You may reach Dr. Danchick at (617) 489-1220 ir e-mail docforiocsfcvaol. com. References Frey C, Thompson F. et al.. "American or­ thopedic fool and ankle society women's shoe survey". Foot & Ankle 1993; 14:78-81. Volpon JB.. "Footprint analysis during the growth period." J Pediatr Orthnp 1994; 14(11:83-85. Liu KM. Shinoda K. Akiyoshi T. Watanabe H. "Longitudinal analysis of adolescent growth of foot length and stature of children living in Ogi area of Japan: a 12 years data." 7. Morphol Anthropol 1998: 82(1 C87-I0I. Cheng JC. Leung SS. Leung AK. Guo X. et al.. "Change of foot size with weight bearing: a study of 2X29 children 3 to 18 years of age". Clin Orthnp 1997; 342:123-131. Riddiford-Harland DL. Steele JR. Storlien LH. "Does obesity influence foot structure in pre- pubescent children?" Inl J Ones Relat Sletah Disonl 2000: 24(5):54l-544.