#39 - 10 Things Every Clinician Should Understand About Orthotics, Part 1

FAKTR, spelled F-A-K-T-R, stands for Functional and Kinetic Treatment with Rehabilitation. Over the past decade, this unique approach to treating pain and dysfunction has been utilized by healthcare providers on 6 continents. Serving as a framework that guides clinical decision-making in patient visits around the globe on a daily basis. With this podcast, our goal is simple: to bring the best and brightest in clinical education to the forefront and empower practitioners with cutting-edge, evidence-based content that improves patient outcomes and inspires healthcare providers to continually evolve their approach to treatment. In each episode, we will feature a training or interview with some of the top minds in healthcare in a short format that is easy to consume. to digest with actionable information that you can implement into practice right away. Let's get started. Welcome to a new episode of The Factor Podcast. I'm your host, Jessica Riddle. If this is your first time tuning in, welcome and thank you for listening. Today we begin a new 2-part training titled 10 Things Every Clinician Should Understand About Orthotics with Dr. David Wedemeyer. When it comes to activities of daily living, one of the most debilitating conditions can be foot pain, affecting both mobility and quality of life. I mean, think about it. How many times have you had a patient come into your office and one of their primary goals is to be able to move better? And whether their goal is to be able to play with their grandkids or finally run that half marathon, the impact of being able to do something as simple as walking or standing without pain can be life-changing. If you're a provider in the physical medicine space, you've probably encountered dozens of companies that market orthotics to healthcare providers, and even those that sell directly to consumers. And while there's no shortage of orthotics manufacturers out there, there is still a great lack of understanding of the medical necessity of orthotics and their clinical use in rehabilitation. Dr. David Wedemeyer is on a mission to change that. Dr. David Wedemeyer is a chiropractor and certified pedorthist located in Laguna, California. A native of Newport Beach, he pursued a chiropractic degree at Cleveland Chiropractic College in Los Angeles and then returned to Orange County to open his practice. He maintained a solo practice and recently retired to focus on his orthotic lab and educating his colleagues about foot orthoses, and pedal biomechanics. Possessing a keen interest in the foot and ankle, Dr. Wedemeyer began investigating the different methods available to fabricate and dispense CFOs, or Certified Fitter Orthotics. He is the only chiropractor to have served the Medicare diabetic shoe bill as a supplier of diabetic footwear, insoles, and AFO braces. Through his podorthic training, he garnered the trust of local orthopedic foot and ankle specialists, and enjoyed beneficial referral relationships with medical providers throughout his career, finally retiring in 2018 to devote his time full-time to operating Solutions Orthotic Lab. In this 2-part training, we will dispel some common myths surrounding the subject of orthotics prescription and learn about the appropriate usage and benefit of orthotics in clinical practice. So let's cue the intro music and get started.

Well, thank you very much, Jessica. I'm Dr. David Wedemeyer, for those that don't know me, and I am a, was a practicing chiropractor for decades in Orange County, California, US. Part of my practice was I became a pet orthist, which is, certified pet orthist is The foot professional that really is trained in evaluating patients, manufacturing and dispensing orthotics, foot orthotics, for foot and ankle specialists, orthopedists, and podiatrists. And I enjoyed for many years some great referrals from those doctors. I worked as a supplier for Medicare for their diabetic therapeutic shoe bill, which basically afforded diabetics with other specific conditions a pair of shoes that were double depth that would allow for soft accommodative orthotics. The idea being there that you didn't want any seams or anything that could disturb the skin of the foot, cause a callus, et cetera. And because diabetics do not heal well and just protect their feet. So I did that and I had a very unique practice. I divided my time between Your typical chiropractic patient and the pedorthic patient, or someone that I saw for those foot and ankle specialists. And I also manufactured and dispensed ankle-foot orthoses, AFOs, braces that go up the leg. So I had kind of a very unique and road less traveled journey in chiropractic. And in 2018, I decided to retire from chiropractic and devote full-time to my lab, which is called Solutions Orthotic Lab, to present seminars. Of course, we had COVID and that all got pushed back a little bit. So I was excited when Jessica and Todd Riddle just asked me if I would do a short webinar. And of course, the subject, as you can see, is 10 Things Every Chiropractor Should Know About Custom Foot Orthoses. So strap in. Here we go. So typically for the chiropractor, we don't receive any didactic training in how to evaluate the foot and ankle from the perspective that the trained professions do, that being podiatry, orthotists, and pedorthists. And this sheet that's on the screen right now, this is actually a sheet that I give to my clients. One thing that I do for them is they provide me a basic examination And based on that examination, I will consult with them and decide on the factors that we're going to put into the orthotics and ship them back to them. Some of the things we will ask for are obviously relevant history, their current complaint, pain levels, maybe Oswestry for the foot and ankle. Yes, there is one. Relevant injuries and any surgeries. And from there, you're looking for some very specific findings, congenital malformations or pathologies that you can see. First one is a Morton's toe, which for those that are not familiar with that, that is a longer second toe, but it actually is a shorter first metatarsal with respect to the second. And I think it's about 15 or 18% of the population. Has this as a congenital variant. And the problem is in gait, when you're trying to propulse, you're shifting the weight to the hallux, to the large toe, the great toe. And in this case, it tends to shift the weight to the second toe, which causes problems leading to gait dysfunction, leading to hallux valgus or bunion formation eventually. So that's the first thing I have them look for. You're going to look at such things as medial arch height, weight-bearing and off-weight-bearing. And there's always a huge disparity and variability among people, but that's an important factor. First ray position. So you're looking at the position staring at the first ray. If this were the toes or the metatarsal heads, I'm sorry, I'm using a cast. I don't have my foot model, but you're looking at a plane parallel to the ground. Are you Seeing a first ray that is dropped or lower or plantar flexed? Are you seeing a second ray that's elevated because of the first condition, et cetera? You're going to look at the position of the heel or the calcaneus, and we'll go into that a little later. Basically, in a position that I use to cast the foot in plaster of Paris, and you're just looking relative to the vertical bisection of the heel. And looking down at the forefoot, is the forefoot— if this— well, I'll go into that later. Are you seeing a heel or a forefoot varus or a heel varus? Are you seeing a compensatory heel valgus with that heel varus, et cetera? And how does it change in weight-bearing? You're also going to look at a lot of other little factors. Ankle dorsiflexion is very important, especially standing. And you're going to examine range of motion at the ankle, range of motion at the first ray, which is very, very important. You need about 40 to 60 degrees of first MTP dorsiflexion and propulsion to adequately perform that. We're going to go in and ask just some basic questions, and this is all on standard order forms that every laboratory uses. But male or female patient, age, Any presenting conditions, as we discussed before. We're going to look at their shoes and especially their activity. Are they couch potatoes or is this an elite athlete? What specifically do they do and should we tailor the orthotic to that activity as opposed to a general one? So I'm really fond of saying foot orthoses are a process, not a product. And what I mean by that is we're very, very familiar with products as chiropractors. We have a lot of companies out there that produce a one-size-fits-all solution, and that's just not how we make those decisions for the orthoses or orthotic. I'll just use that term. I'm going to show you the process next, and the process I think needs to be understood so that you realize there are companies out there that we're familiar with that when you order, you get the same device back every time, same material, practically the same topography or surface area, etc. And in podiatry, especially in people that order from— or practitioners that order from other labs, you'll notice there's a huge difference in the type of devices and the type of material, that there's actually a shell made of plastic, polypropylene, composites, etc. And that becomes very important. But it all begins with the history, the examination, and the cast. And we'll go briefly into casting, the different methods, but it's very important. That cast really serves as the basis upon which we'll build and build that orthotic device. You need next to identify the dysfunction. What kind of pain are they having? It could be something simple like plantar fasciitis, which is typically— a loading problem where the medial band of the plantar fasciitis in typical PF cases is overloaded, and we have to make decisions to unload that and allow that tissue to heal. You need to formulate a treatment plan. So this is not something that's new to chiropractors. We have to do that, especially dealing with insurances, et cetera. You want to formulate a treatment plan for that patient and document it. And the big thing is to have a goal. That's one thing that's very much missing. What is the goal for that patient? It could be simply to allow them to perform their work duties, their ADLs, et cetera. Or we could be trying to improve a function like in a runner. Maybe they don't have adequate first ray dorsiflexion and they have a functional hallux limitus. There are ways to improve that function. That we can go into later in either subsequent webinars or the webinars that I'll be producing as well, and also seminars. So from there, we're going to implement the design and the features of the orthotic. One thing that is not well known to chiropractors is the features of the modifications that you can make to the orthotic device to influence those functions. And that is something that we'll go in depth in. We don't have time for all that today. This is just a webinar, of course. And then from there, you want to dispense, code, and bill, of course, if you're using insurance, which is a topic that all of these things that I've included in this webinar are questions that I frequently get from providers. And we'll try to clear some of those up today. So there are Different casting methods. One particular company has used foot scanners that you stand on or you step in a foam box. That's not something that we even accepted at my lab. The reasoning behind that is that full weight-bearing versus semi-weight-bearing foam versus an off-weight-bearing cast, the non or semi-weight-bearing and full and non-weight-bearing casts produce a very different shape. They all produce different shapes.

Okay.

And if you look on the bottom of that picture, that is a full weight-bearing cast in foam. And from there, they would take the foam, pour plaster in that, pull that plaster out, flip it over, and you have a positive mold. So all 3 of these before the digital age, that's how we did that. And we worked off that plaster mold. Now it's all done on a screen. And we'll go into that when I show you the process next. But the bottom picture, you can see how low that arch is. There is no arch. It's almost a pancake. It's so flat. This was actually a colleague that was having problems that I met years ago in another colleague's office. And I produced these 3 from his casts and just to show comparatively. So on the bottom, you have that very flat cast, the middle positive mold, You can see it has a very nice arch, semi-weight-bearing. And the top is the plaster finish mold where we actually took, and it was very similar to the middle mold, but we added some plaster expansion, which just means we kind of like adding icing on a cake. We put some plaster on there to allow for some pronation of the foot. And so you can see they're very, very different. We also now have methods digital methods where you can buy an inexpensive, I think it's about $500, $600 called Structure Scanner. And we now accept molds where you can scan the foot digitally and upload that to us and we can obviate using foam, plaster, and the shipping process. So from there, from your mold, and you can see on the right side in the foam box, The upper foam box mold is actually that full weight-bearing foam mold, and you'll notice that there's almost no medial arch in that foot compared to the bottom one where we had a semi-weight-bearing. So the whole premise behind that is if you stand in something and let's say you have a very flat foot or an adult flatfoot disorder where the medial arch is completely obliterated, and the heel was in valgus, you cannot correct that mold, not legitimately anyway. So in the same patient, taking the mold at the bottom, we actually have a medial arch, probably a better lateral longitudinal arch, and a better representation of the topography of that foot from which to start and scan in and change the orthotic. And influence that foot. On the left, that's just one day in my office, all the plaster, and I took some foam molds as well. So production-wise, we take that impression and we scan this with a laser. So we'll take that mold and plaster cast and scan this into a very complex system, and it gives us a perfect representation of the foot. So what this is One of the systems out there, we have 2 systems that create, take analog such as the foam molds and create them into a digital representation. So this comes up on my technician screen and from there you can see the outline of the foot. That's a near-perfect representation of that patient's foot and this is the building block that we will work from. We scan it in and from there we can modify it. We could put pressure relief areas, we can post, which if you're not familiar with posting, it would simply mean there is a rear foot post. So very common for our devices to carry a rear foot post. There are times when we'll just grind it flat and you will not have rear foot posts, but this adds a lot of stability to the orthotic.

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There's also posting that can be done intrinsically, meaning within the device itself, or extrinsically on the outside. So you might have on the inside of the device a varus post or add a varus heel post, and you can do it on the lateral side. A lot to go into, so we will get to that in future Trainings. So after they modify the mold, what we will do is send that to our CNC mill, and the mill creates a positive mold from which we will make the device. We use wood blocks and foam blocks that are CNC milled per the scan that we've created with the modifications. After that block is milled, we will then heat and Use typically polypropylene plastic as the most common material. It will be heat and vacuum formed and over the block that we create. And then if there are extrinsic posts, this would come actually after the initial intrinsic posting or, or et cetera. And we will add and subtract to the device, fill in areas according to your prescription, or in this case, a lot of times the prescription that I help you with. Then we have technicians that grind and shape the orthotic and make it look nice. I do this, I spent a lot of hours learning this as a CPED, but typically when you become a ped orthist, a lot of them work in labs manufacturing. And so I know how to do this, but I'm not quite as good. I have a couple of guys that have been in this industry for decades who are much better at it, but they are wizards and it's amazing actually to watch them. Someday eventually we'll have tours of the lab and— Allow people to see what's going on. I never found that exciting, but I get asked that question. Would we allow people to do that? We'll get into that later. And from there, we will cover the device. There's so many different materials available. Real common ones are Spenco, which is actually like a wetsuit material and my favorite top cover. There's vinyls, leather, et cetera. So you can offer your patients quite a A wide array of top covers. And underneath and between the orthotic and the top cover, a lot of times we will add Poron, which is a blue layer you will see. And that is a device that disperses forces and adds to the comfort of the device. On the right screen, you see that there's an extension underneath that top cover to the shell. More padding also makes it easier and stiffens this area. So, so that it's easier to get in and out of the shoe. And then there's, of course, final shaping and polishing. We buff it out to make it look perfect and uniform to send back to you so that it's appropriate. Everyone is pleased, the doctor and the patient. And those are just some finished products, and you can see some there are black polypropylene, which is our sport device, our most common device. There's a shorter version. Second over from the left, that is a composite material graphite. We have many different graphite materials, different compliance, let's say, or material properties that will allow for a heavier patient. Maybe it's stiffer, like what we call Carboplast, which is what I favor. I love a very stiff orthotic. These are chosen, and the thickness of the shell is chosen by individual weight and activity, etc. Sometimes the same device that we make for everyday wear, we will tone that down a little bit and tone the modifications down for a sport, let's say. A lot of options. This subject is always asked and we kind of touched on it a little bit talking about weight-bearing scans, et cetera. In my history, what happened, I initially owned something similar to what's on the screen and I thought, great. I'm going to be the orthotic god and dispense these. And I was very excited about it. And then I started to learn more and more about the methodology behind these 2-dimensional pressure pads. They're kind of a great idea for gait or gait analysis. And there are very expensive systems that perform that function that not many people have in office because I believe they cost about $6,000. But you have to understand that a 2-dimensional form of capture like this can only capture the length and the width of the foot. It cannot capture the surface topography or geometry. So what they build into these devices is essentially an algorithm to guess. So I'll repeat that. It is an algorithm and a guess. It is not— can you imagine if dentists took molds in your mouth and guessed? So it's the same with the foot. I think it's very important to get an accurate capture of that individual's foot. So I ended up letting go of that scanner and giving it back to the person actually that manufactured it. From these scans, what is created, or in our lab, what is created is a library. And that library just consists of a library of foot shapes. And why that's important to understand is I found out years ago, every single one of these pads produces a library shape that is a close guess. And they're pretty close, to be honest. But when you're advertising a custom orthotic, I think it's just disingenuous to say it's custom or term it custom and then go pull a shell off the shelf that looks very similar. But is not truly custom. We don't do that. We have a library. We've considered offering prefabricated orthotics, a library step where we could do minor modifications, and then fully custom. At this time, I only produce custom orthotics, and we're never going to commingle those. So that's something to be aware of. Many of the large companies get bought up by IPO groups or financial groups, the largest lab in the world was, and I used to use them to produce my orthotics before I did it myself. And I found out they were using a library system. I had a lot of returns for modifications doing that. Our return rate off our custom orthotics, especially because I'm doing the work for most doctors until we can get them trained, it's really low. And that's very pleasing to all of us. So the accuracy in these devices is really questionable when you're talking about calling it a custom orthotic. It's more of a customized orthotic. So the limitation there is that you cannot get a truly custom device from a library system. And I kind of, I touched on this, but what does custom mean? Custom means to me when you tell a lab or a lab advertises that you will get a custom individual device to your patient, that that's what you deliver. Right. And we kind of went through that. This is the proof in the pudding. So we have a very popular brand that is sold within chiropractic, and these made their way into my office. I never ordered from them. I did get a pair when I was in college, and this is a very common tactic, is to provide a free pair to give money to colleges. They are the giant in the room, but This is something that I get asked a lot. Is it an orthotic? Is it a custom orthotic? And in my opinion, that's an insole on the bottom. This is the same patient. She was a workers' comp patient. A colleague had provided her that brand insole on the bottom, which by the way is made out of materials that we may fill above and below an orthotic shell, such as plastic or carbon fiber or graphite. And we may fill that kind of like you have different layers in a shoe, but it's made solely from those materials and then top covers. And then what always grabbed me or caught my attention was the expense of the device. They're quite a bit more expensive to the provider than what we produce. We have a standard fee that covers all modifications. And anything we do to the device or your devices. But look at the difference in the arch height. I took a plaster of Paris or POP, I'll use that term to describe plaster of Paris molds. Judge for yourself the arch height and the difference in the shape of that foot between what I made for her and what is below. So when you ask a lab, do you produce custom devices? You can't always take them at their word because it's a word that's very generic and used very interchangeably among some of the labs that I say sell a product or use library systems. And we just don't equivocate and do that. So I wanna run through some common myths. These are things that I get asked quite frequently. You would not believe the number of direct messages I get on Facebook. I try to avoid that. At the end of this webinar, I'm going to provide my phone number. Because of my situation with my eyes, I prefer you call me or send me an email, and I prefer phone calls. I am always available and open to anyone to answer your question. I realize some people on this webinar may be abroad. You can always email me and I'll try to answer your questions in a timely fashion. But let's go into some of the questions that I get and the popular myths surrounding foot orthoses. So my favorite is this marketing mantra that is used by a company that most of us are familiar with, and they claim they support the 3 arches of the feet. I'm here to tell you today, based on the evidence, and I have, I believe, 8 of these studies, actually, Hewson, I'm going to reference first. Hewson was a very brilliant orthopedic surgeon who did a lot of studies on the foot. How it functions. Brilliant guy. He came along before Kapandji, who I believe in 1970 or the early '70s referenced the foot as a tripod. And ensuing slides, we will discuss that a bit. So he, Kapandji, actually referenced the foot as a tripod where the heel or calcaneus, the 1st metatarsal head, and the 5th Metatarsal head acted to bear all of the weight and there were 3 arches of the feet. Prior to his assertion, Cusson actually looked at the foot and through his studies, and they used force plates to measure the amount of pressure that was borne on each individual metatarsal. And they found that there was a weight-bearing function for each 5 metatarsal heads. And any of the Research that I, or studies that I reference in this webinar, I can put them together and make them available. So all you have to do is ask. But Houston is just one of the studies. Reference a German study, force plates again, and they found the same thing. So there's just too much evidence here that that 3-arch representation is a myth. There's a weight-bearing function definitely for all of the metatarsal heads. You could try it yourself. When you're standing, do you feel all of your metatarsal heads, the ball of the foot touching the ground? In most cases, you will. The only time you would see this tripod alignment is in a high-arched, rigid cavus foot, and then I agree. But that is not normal. So we talk about Kapandji on the left of your screen. You will see that representation where there's a triangle that shows an area of contact with the ground, not so much in the medial lateral arches. But on the right, and we look at the studies and we find that's just not true. The whole point behind this is if this is where you're getting your biomechanics from, it needs to be updated. And you need to think about possibly updating your knowledge as I did. It's a marketing tool. Let's talk about another one. It's real common, and especially in physiotherapy forums too, and they love to bag on Podiatric, quote, orthotics and how they don't work or how they're too rigid, how they weaken feet. There's a huge barefoot discussion. I found the whole barefoot trend to be really fascinating. And I'm friends with a lot of the podiatrists and researchers, et cetera, that lecture internationally on pedal biomechanics. I know I'm getting off track here, but we have a little bit of time today. When that all started, I found it interesting, but I found some of the claims being made to be spurious. And as you know, Vibram created a shoe that was really like a rubber sock and made a lot of claims that barefoot was the be-all, end-all, and cure-all panacea. And I said early on, if you change to a forefoot strike from a rearfoot strike and you're using different tissues, you're loading different tissues, I'm going to guess that you're just going to see the same injury rate, but different tissues being injured. And that's what it bore out. That's later on when the studies came, that's what happened. We had a couple of well-known chiropractors who were on the board of Vibram and a podiatrist, and they promoted these claims. And I found caution in that. I said, we don't have the research or studies to make those claims. And I'm always cautious about research and making claims. Those who know me will tell you I'm very straightforward about what I say and looking into things before I say it. Bottom line, Vibram got sued for their claims, and that's that. So one of these new claims that I see a lot that's currently a topic is that orthotics weaken feet. Based on the studies, and I only like to present studies that have at least moderate level evidence behind them. But based on the studies, this just isn't true. They actually— these 3 studies, and there are more— they did electromyography on people in an orthotic condition where they put that in their shoe and did various permutations of that orthotic. And what they found is there was actually an increase in EMG activity, especially when they wedged the orthotic a certain way. They elicited very strong Response to the peroneal muscles. So the peroneal muscles are really important in toe-off because you have such a strong resupination of the foot. The peroneal muscles are a major everter of the foot. They also provide eversion, abduction, and dorsiflexion. So when you go load into stance and you're coming off and your heel lifts off the ground, they're very active. And these studies really refute that orthotics weaken feet. They're below the level of the foot. I used to build and dispense AFO braces, which would be similar to taking the orthotic device and taking that plastic as one piece all the way up the leg. We use that for flatfoot where you have a very, very pronounced and dramatic medial longitudinal arch. Flattening and a progressive disorder where heel valgus follows, and then something called the too many toes sign. You look at the foot from the rear, and that heel would now be tilted inward in extreme heel valgus. We would correct that in the casting of the foot and build a brace to limit that dysfunction and the progression. It's sad, but often it is the sequela of the condition, and all you can do for that patient prior to surgery. is provide one of these braces. We know that bracing does over time can prevent atrophy in the muscles and a functional weakness. It's just not true that orthotics do that, that I've seen. This is a really interesting subject, and it goes to the roots of, no pun intended, of the nexus of podiatric biomechanics in the, I believe, the '50s, '60s, Merton Root was a podiatrist professor at California Podiatric Medical College, and he, along with Bill O'Reilly and John Weed, these are names that I'll present in courses because I think a background in understanding how this evolved and what we're using today and a lot of what's taught in the pedorthic, orthotist, and podiatric programs, a lot of this is still used and Merton Root still deserves credit for taking and collating a compendium of information on how to evaluate the foot biomechanics. So the bottom line is one of the notions at that time was that an orthotic would improve alignment. So you see down here, we have a heel that's in extreme, pretty good valgus, and that if you put an orthotic underneath that foot, you would correct that bisection to where the heel was now vertical and that would improve function. And we'll talk about this later, but the problem is orthotics don't always predictably perform that function. So we've had to kind of move on to that architecture versus kinetics and motion. And that is another myth that I see, and I still see it all over the internet and advertising, et cetera, for labs. But we don't— we'll look at that relationship, especially in weight-bearing. But it's not a reliable predictor of the function of the foot, just a finding. So I'm really fond, or I learned from one of the professors that is my mentor about kinetics versus kinematics. And kinetics is the study of forces that cause motion, and it's really the study of forces in motion. Kinematics is a description of that motion that doesn't really relate to forces. So you're looking at more of an architectural or structural thing. This is really akin to some of the debate within chiropractic about the spine. Believe me, it's heavily debated in podiatry today. So you can have a change in kinetics or forces without an appreciable change in kinetics or structure. But you can't have it the other way around. Anytime that you have a change in— you will always have a change in kinetics or in motion, but you may never see a change in alignment. And that'll go a long way later on to understanding tissue stress theory. Another myth is that, oh, those podiatric or podiatrist orthotics are really uncomfortable. And comfort is a function of too many— there's a lot of nuance in there. There are too many factors involved. The main thing is they're always described as, oh, those rigid orthotics, and it's just not true. Orthotics are chosen mainly on the individual patient's foot flexibility, their weight, like I said, their activity. I, for example, have a very high-arched but a very, very flexible foot that pronates quite a bit. I also have a forefoot valgus, I noticed that softer orthotics tend to cause more problems, probably because there's no posting in the forefoot, and I wear a very rigid device with a top cover to soften it up a bit. So this is a big fallacy or myth. The most significant feature of a custom orthotic is you are taking a representation of that individual's foot and you have more contact surface area on that foot dispersed over a wider area. And that really, to me, between that and the material, that's where you're going to find your comfort. Also, there are a lot of different materials you can put over the top. I talked about Poron. We have one that's called slow-reacting Poron that when you push down on it, it takes a while to rebound. And we use that for diabetics a lot. I use it in a lot of patients with hot spots. Maybe they have metatarsal pain. It's a lifesaver. So comfort is not determined by the rigidity of the material or lack thereof. It's really a function of designing a good custom device. And I have a study up there that bore that out.

Guys, that's it for today's episode. Be sure to tune in for episode 40, where we wrap up our training on 10 things every clinician should understand about orthotics. We will discuss the difference between a 3D volumetric cast and 2D methods, and how they impact the finished device. We will also learn about the marketing and myths that entice doctors to buy generic brands. Buyer beware! Guys, this information is absolutely fascinating, and I highly recommend you click the link in our show notes to watch the full webinar so that you can see the visual presentations as well. You won't want to miss it. Episode 40 drops in 2 weeks. In the near future, we're also planning a few special Q&A episodes with our past instructors, so please be sure to click in the Q&A link in our show notes and ask any burning questions that you might have. You can subscribe to The Factor Podcast on Apple, Spotify, iHeartRadio, or the podcast app that works best for you. Please give us a 5-star rating to help us grow the show. Every little bit helps. And last but certainly not least, be sure to visit the show notes for a link to download the PDF of today's full presentation, as well as learn about any special offers that we featured in today's episode. We'll see you next time. Hey guys, if you like what you heard today, I encourage you to visit our website at factor-store.com. That's spelled F-A-K-T-R-store.com to find out more information about all that we have to offer. We have a variety of online offerings as well as our hands-on Factor Rehab System course scheduled in cities around the globe. Be sure to also check out our event calendar and bookmark any of these upcoming live webinar dates coming up in the near future so you can join us live. And of course, the biggest compliment we can receive is for you to help us spread the word to your friends, colleagues, and classmates. You'll find all the important links as well as info about our sponsors in the show notes, so be sure to check those out.