298- Custom Orthotics Explained by Dr. David Wedemeyer

Welcome to the Evidence Based Chiropractor where each week we deliver the latest chiropractic research and marketing strategies all in the time it takes to get to your office. Now, here's your host, Dr. Jeff Langmaid. Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langme. Today's episode is all about orthotics. I know this is a topic I have been personally super confused by. I think the information out there is great, but it's hard to get a handle on. And I wanted to go to who I consider to be the number one expert, ask a bunch of questions and really start to set the stage for what? How can you use orthotics in your practice? What are they good for? And what are the experts seeing out in the field? That is why I invited Dr. Dave Wedemeyer on. He is the founder of Solutions Lab. I'll drop that link down below. We talk about a lot related to orthotics. This has a ton of clinical relevance for your practice and he is a straight shooter. So this is a great, great episode. Before we get started, I want to say a few words about E Chiro ehr. Every EHR sells features. Few have E chiro's expertise. They can help you create a better lifestyle and improve your practice health. You can check them out@echiroehr.com Again, that is e echiroehr.com I'll drop that link in the show notes. Without further ado, here's my interview with Dr. Dave Wedemeyer.

Yeah, I'm really pleased to be here. Thank you, Jeff.

My pleasure. Before we get to what's going on today because you and I were just talking about some exciting things coming down in the future, I want to peel it way back. What got you interested in orthotics to begin with?

Actually, you know, it's the same old story, like with a lot of chiropractors having an injury or something that led them to the chiropractor and they had such a great experience. Mine was the opposite. I was having some foot problems right about the time I was graduating chiropractic college and I received a pair of a brand I won't name but because that wouldn't be correct. But I knew nothing about the subject and I put them in my shoe and it actually, in my case, it made it worse.

Okay.

And I ended up going and seeing a foot professional podiatrist and the orthotics they gave me really didn't work either. And I thought well, you know, if chiropractic works on a mechanical basis, I can understand how something under our foot, whether it's a shoe or the orthotic, could do the same. And so I started delving into it. I found a form that was populated with podiatrists, and for chiropractors that don't know podiatry really created this. This whole thing. A gentleman named Merton Root, who put together a systematic way of evaluating patients, did the profession a lot of good. And before they did surgery, that was their main. One of their main forms of treatment. So I delved into it. Like I said to you earlier, no roadmap. Met a lot of podiatrists, went to their conferences, started tinkering with them myself and. And learning and reading their texts. And it just opened my eyes and I went, wow. So basically, the more I knew, the more I learned, the less I knew. Yeah, it was just so vast, and it is. It's a heady subject. I don't expect that every Cairo is going to be interested in it, but we have a lot of them dispensing orthotics. And my concern is, do you have any training at all? Do you understand the. The difference and the different mindset of practice laboratories and what they produce? So it got me on a long road that I'm still traveling.

Well, I think that that's great. And I want to talk about some of the common misconceptions out there, but before we get there, let me ask you, what are those two or three big items that you just think every chiropractor should know? Like, we're talking Orthotics 101, the super basics. What are those things that docs. Every doc should know, either if they are doing it currently, definitely they should know, or. Or if they're thinking about doing it in the future.

I think, first off, you should know or understand what you're looking for. What does an orthotic do, and what are you looking for? Number one, in my practice, I became a certified pet orthist who has training mainly in manufacturing and in footwear. And for me, someone might see. See a patient, have them stand on a scanner or something and say, your arch profile's off. Pronation. My favorite word. Don't get me started on pronation. But I might see a different population of people with definable diagnoses. Posterior tibial tendon dysfunction, metatarsalgia. Common and simple. One, plantar fasciitis. And I'm not saying that other chiros don't do this or see this. But do they understand from taking that diagnosis to the orthotic and what they can do? What are the shells made out of? What does your lab do with it? How can you change that shell or alter that shell to mediate those faulty biomechanics that may be causing it? So that's one thing they should really understand. It's out there. The second one would probably be that they're over prescribed.

Interesting.

Real honest. I'd love to sell more every day, but in all honesty, I would rather, I would rather manufacture for doctors who had a little bit of didactic training and knew what they were doing and were not just rushing to a custom orthotic every time. Not everyone needs one.

Gotcha.

And you just heard someone that owns a lab say that to you. Not everyone needs one. There are instances where an over the counter orthotic will suffice. Taping, changing footwear. I'm big on that. And then third, I think, I think they should know that there is a program coming up. I hate to do this, but I'm gonna pump myself. Yeah, we had seminars set up for last year. Covid destroyed that. And my goal is just to give them a bare bones, common sense day and a half seminar that, that teaches them what they need to understand, what to look for, what materials to use. Pathology based. Okay, we're going to update our forms and you'd be able to say, well, they have plantar fasciitis and this and boom. We would just based on their, you know, certain parameters, their foot flexibility, their height and weight, are they diabetic or not, etc. They would get a turnkey orthotic that I always used for my patients. Make it, make it. So I want them to know that there are mainly, there are better labs out there than we're currently using for the most part. There are better designs and there is training and there are people that have this training that you can go to if you don't feel comfortable, send it to a pet orthis with a script. Send it to an orthotist, a podiatrist.

I think that's super cool. And I want to dive into. Some of you mentioned the didactic training. I think that's super important. We'll drop those links down in the show notes below as well so docs can hook up with you. But when we think about orthotics in our practice and the didactic training, and I know this is a deep subject that you've spent years and many moons studying, but if you think about just the real super basics. As a novice myself, admitted novice, what are maybe those two to three diagnosis or challenges that a patient might be experiencing that I'm like, man, that's starting to lead me down that orthotic path. And maybe what's one or two where I'm like, yeah, that's probably not the right direction to go.

Well, first of all, you have to understand our. The way that podiatry, the way that labs are set up, what they do with your cast, a lot of it was. And this is something we could go on for hours, bottom line, something that has been kind of questioned and it has to do with seeing the. From, you know, looking from behind at the foot, looking at the calcaneus and looking up a vertical line up the lower leg. And then from there you look at the forefoot. The relationship, if that rear foot is vertical, which is. It isn't always. And an orthotic doesn't always make it vertical. So I don't rely on that. That's old, old theory that has some basis, et cetera. But now I wish I had a. And I might be able to find it on my phone. But you're looking at that relationship. So you're looking at. We've heard of four foot bears and I'm going to try to find a picture to make this stand out to you. What's funny about that? You always hear about pronation, you always hear about four foot bears where the foot, if looking from behind the forefoot is inverted relative to the rear foot. That is extremely rare. Okay. So what I see is in a lot of casting, they're creating that in the cast or if they have aquinas, meaning a situation where their heel cord, their Achilles tendon, their gastroc is tight or the heel cord is short and the foot is plantar flex downward. Okay. And it's inverted. So now you have that relationship. I see it being created in casts all the time. And there's even an orthotic company that favors taking the midfoot and supinating, which creates that. That's really rare. Pronation is normal. It occurs at certain phases of the gate, especially mid stance. It's abnormal. Once the heel comes off the ground, you really don't want your foot to continue supinating. You have to pronate, get your the majority of your weight on the hallux, the first ray and to propulse. So what is More common is 4 foot valgus, the other direction. And I don't want to be rude, but I will look for that picture in here because I have a really wicked four foot valgus in here. Woman went to seven different people, brought in a bag of orthotics. So there's the other thing. Orthotics don't work. Yeah. Because they didn't know what they were doing.

Interesting.

And she, she got a lot of orthotics that would pitch her even further into supination of the subtalar joint and, and forefoot varus. So now she comes in and she has a horrible perineal muscle spasms all the time. Can't ski. She's a runner. 19 years old. Bottom line, I made her an orthotic. And if you want to go into it later or provide that, I'll show you what I did and it makes sense. And instead of putting wedging on the medial side of the foot, I put it in the forefoot on the lateral side. Her pain went away. She put a Google review up for me. Very happy. But that's the kind of thing if you don't know what to look for, what are you really giving them? And that's my concern. We should. Chiropractors could be so good at this. Podiatry is losing their interest in biomechanics and we're very well versed biomechanically. We're just not being presented, I think digestible chunks of biomechanics to where we could really up our game. And I think with a little bit of training we could do better. What was your original question?

No, you hit it. Which was a couple of those things that doc should be looking out for and maybe a misclassification or two. And I think you did a great job kind of breaking some of those down. And my follow up to that, I know you're taking a peek for that, for that snapshot there, but my follow up to that will be around. This is a very basic question, but if somebody has an orthotic, you mentioned relief. Should this be something that they should feel relief quickly? Is it something that they got to wear in and it's going to be uncomfortable for a little while? Is everybody a little bit different? What's your experience in how a doc can gauge, for lack of a better way to say it, whether it's working? Obviously there's a physical examination component.

But.

But as, but as far as the patient's symptomatology and how they're explaining things visit to visit?

Well, a lot of it, it's kind of hard to measure. We don't have Inshoe EMGs and things in gait analysis, typically, although it is out there.

Yeah.

And if you want to be the superior one at it, you can utilize that. But the bottom, a lot of it is subjective. You can see some objective changes. Sometimes you can get kinematic changes. Really? Meaning without motion, you're just looking at a static position. You know, certain chiropractic techniques are big on that. What you see on an X ray, you can get a kinetic change or both, but you never get a kinematic change without a kinetic change, meaning motion without changing motion. So you can change joint moments, etc. You can have the patient and tell you subjectively. Yeah, that's, you know, it was a 10 of 10 today. It's a 5 of 10. You have to follow up with them. But I know this and, and I dispensed a lot of orthotics, 25 pair average a month on referral. So I'm not the typical guy. I was kind of acting as a pet orthis more than a Cairo in that respect. Yeah. I had two absolute rejections or returns and both of them said, I don't even want my money back or anything. You tried. So is it a panacea? No. When they stand on that orthotic, if they're comfortable right off the bat, you won't have to adjust it. And you know, they're going to be comfortable and it will help them. And most acute things, the relief is almost immediate. Plantar fasciitis. I do low dye taping. Okay. I can make that available for docs, but I did a specific figure 8 configuration from the metatarsals around the heel and back up. And if I thought they had plantar fasciitis, I'd tape them. And if they walked on it and they felt better, they need support.

Yep.

You don't even have to use a lot of heady brain work to realize something is overcoming the fascia. And even more importantly, probably the posterior tibial tendon possibly, which is something we should get into. I'm hoping you're going to ask me about the plantar intrinsics because I have something to say on that subject. But bottom line, it's a fascinating thing that's kind of going on. And the good news is we're going to be able to obviate both plaster and foam pretty soon. So later on I'm sure you'll ask questions about that in a very simple way. But if you stand on the ground, do you think you're going to capture that and then be able to mediate it? No, no, no. It's, it's simple. Casting is the very beginning and it's something that I want to teach Kairos and get them comfortable with. A lot of them are really kind of timid about it. It's not that hard. I train my staff to do it.

I think that. And let's, let's dive into some of this because I know there's so much misnomers around it. You brought up, you know, plantar aspects, plantar fasciitis and that. I'd love for you to drill down on that. I was going to ask the question, what are some of the biggest misnomers around orthotics and around how docs are thinking about it? And it sounds like that's one of them. So what's up? Tell me about, tell me about plantar fascia. Plantar fasciitis. Again, this is a world that I'm excited to learn, learn more about. So what are you hearing out there? What do you know to be the truth and what should, how should docs be thinking about it?

Well, years ago, a very notable podiatrist down in Australia, I believe his name is Carl Landorf. And, and he's at one of their huge universities, him and a guy named Craig Payne, big podiatrist that I learned a lot from. And Landorff did a landmark study that we didn't like as people that provided orthotics because it cut into business. But what he gleaned from that, that very large, very well done study, was that prefabricated orthotics were just as effective as customs.

Okay.

For plantar fasciitis, for that one condition.

Okay.

So when I hear chiropractors quote that and say, well, prefabs are just as good. Well, no, for that in that study, and I'm not going to say there are competing studies, I would say that custom is a very subjective word. Not that I'm the greatest at it, but me and the people that taught me the way that they do or approach orthotics is quite a bit different. So you get a lot of chiropractors, oh, you have plantar fasciitis and they stand in a loaded position and take a cast, whether it's digitally or in our case, we opened up one of those machines, by the way, and it was a desk jet printer. So I think they use a laser now. But what does it matter? If you put the foot in a loaded position, you capture the deformity. How are you going to alter that? Unless you use some kind of algorithm and do it with your software. Right, we don't do that. We want an unweighted or semi weighted, which are what work. It's not even any debate. No trained profession does a standing weight bearing orthotic anyway or a cast and none of them use an hp. It's not, it's not that simple. In our day, I mean there was a guy named Shang and he created a scanner that is a laser. The scanner, those lasers were 15 grand. I think they're down to five now. But the funny thing is you can get something for your iPad is pretty much as good. It's 500 bucks. And that will be the future. But going back to plantar fasciitis. So my, my rationale was always pathognomonically first step, morning pain, like an ice pick, gets better as they move throughout the day. It's all you need. It's plantar fasciitis. What causes it? A lot of things. I mean that's why there will be courses. There's no one cause there are conditions like that four foot valgus or excessively pronated feet and late mid stance that will cause overuse injuries. Just like we have overuse of it, all the other parts we treat. So for me, I, a lot of people would say start out with an over the counter orthotic, assessing their shoes, making that they were proper and appropriate for them. I had a lot of barefoot people that had gone in shoes their whole life and you don't want to get me started on that. I have some thoughts there. But, and it's not all bad. I mean there are people I think that are more well conditioned athletes or weekend athletes that can do some of that. But the bottom line, if they stood after being taped up and they felt better, let's, you know, let's look at a, let's look at an over the counter and is there shoe wear, footwear completely worn out or non supportive? Maybe you could start there. So not everyone needs to go there right away. But I will tell you this. The chronic cases I got, I had a real high success rate. And I would tell acute patients, let's, let's go step at a time, let's see in a week, two weeks, a month, etc, I think you can get through this. I always gave them specific exercises, icing, which a lot of people don't like, but it works in bad cases, believe it or not. Cortisone, I don't believe in getting a lot of it, but early on getting that inflammation down and you have to realize there's plantar fasciitis, inflammation early, then there's plantar fasciopathy. So after months or years or whatever, now you have a progressive degenerative change. Nobody's making that distinction. They're immediately going to one or the other. I'm going to do shockwave. Well, on a, on an acute case.

One of the things that you mentioned that I'd love for you to break down a little bit are the different materials. Right. You know, so what is, what's out there? What's the, what's the difference between them? What do you personally, you know, like, is it a case by case basis? I guess, you know, for, for somebody new to the, new to the world of orthotics? What's available? What should be, what should I be looking for?

Well, let's get rid of a couple more myths. First of all, everyone likes to call podiatrist type orthotics rigid or hard. And they do call certain plastic and composite shells semi rigid. But they all have a flexibility. So when you look, when you evaluate a patient, like, I used to treat a lot of diet. I don't know if you know this. I worked for Medicare as a supplier for a diabetic build. And this is similar to a diabetic orthotic, multiple layers, soft, no plastic shell, typically flexibility. This is still kind of firm, but I used to supply shoes and diabetic insoles, three pairs of them or a custom pair every year. So when you get a diabetic, it's a whole different ballgame. To answer your question, you need something and including, you know, the shoes need to be double depth so you can put something in there that's thicker and it's accommodative. You're just accommodating their foot. Maybe you're making things for hot spots. You're basically trying to ensure that their foot doesn't get an ulcer because ulcerations don't heal in a lot of diabetics. And I can't tell you how many amputations I saw. And if you want to meet really unhappy people, they start losing toes. The next thing you know, we're building something into the front here that's basically a partial foot prosthesis to meet the stump. When I say stump, I mean Liz Frank joint. All the toes are gone. So softer, softer materials for a purpose. For accommodative, the most common. This is a polypropylene plastic. Make sure those labels say my name on there. Not someone Else because we make stuff for other people. But plastic is the most common. We call this a sport model. It is a semi rigid shell. It has some flex. See if you can see that. Yep. Has a little bit of flexibility. You put £150, £200. Yeah. And the shells differ in size accordingly. What do you want? What are they using it for? So this could be a composite. Okay. And it for a dress shoe. It could or could not have a heel post. We grind that flat, make less volume. So these. I have a couple pairs of these myself. Runner specific, multiple layers. There's a blue layer poron for support. Thinner shell, more flexibility. Maybe less restrictive heel cup. Because this heel cup is important. Go look at the major brand and notice they don't have a concavity in here. They have a convexity. I don't understand it. That's not how you're feeling. Is shaped right. So then we might have some padding in the forefoot for your metatarsal heads. It's specific for a purpose. So we have all different kinds of stuff. A child's UCBL or University of California, Berkeley. And I want to say something about this. Billing codes L3020, L3030. I used to always use L3020. This is a billing code. L3000 for children. It pays better. Do not use this code for your functional adult device. Don't get caught doing it.

Good tip.

But anyway, this is a plastic. Very controlling for pediatric flat foot. Not every child that has flat foot will have it forever. You know, hopefully by age 7. They. So I'm not. Plus they grow out of them quickly. Yep. You know, gets expensive. They do sell over the counter ones. Hit and miss.

Okay.

I know when we make these we require a plaster cast because it's very intimate, but there's a lot of different. This is just a service surface. The top cover materials eva, which is the same stuff on your bottom of your shoe. Vinyl. I don't have it in front of me, but I'll dig around back here.

My.

My extra room's full of orthotics. You would shudder if you look back, but there's something called sp, which is my favorite. And it's like wetsuit material. Okay. It's antimicrobial. You can get it in different thicknesses. So just knowing these, you don't need to know everyone. But knowing a few different choices, you can offer them to your patients then.

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Sam.