Dear Physical Therapy Class:
It was my pleasure to give you a lecture on the care of Diabetic Feet. I certainly hope you walked away from class having learned something.
ORTHOTICS: We use several different types of orthotics in our office. The first question one asks when considering what type of orthotic to use is “ What I am trying to accomplish with this device? Is there a device that can be helpful to my patient’s needs?” This will steer you towards a choosing a specific device.
We use accommodative devices(i.e.-plastazote/poron) for patients who need to offload areas of pressure, like a callus or ulceration. These can be added to an extra-depth shoe, running shoe or a surgical shoe. Often times, if a patient with an ulcer comes into the office and their shoegear is inappropriate we will dispense a surgical shoe that we add poron on the sole with a custom cutout. This is easily added with rubber cement. There is usually a charge for the shoe(Durable Medical Equipment--sometimes insurance pays, sometimes it doesn’t).
We also use semirigid devices for patients who have an area that needs to be offloaded and may also benefit from some mechanical support. Usually this consists of a multilayered orthotic with a plastazote topcover. We do not usually make these in our office. We refer these to orthotists(like Hangar Prosthetics in Columbia--they would be a good resource to call). Medicare allows for 3 pairs of plastazote inserts along with one pair of shoes a year. I have not yet had a diabetic patient be refused, although usually one needs to document things like LOPS(loss of protective sensation in at least one dermatome per Semmes-Weinstein 10 gm monofilament test) or peripheral vascular disease. These shoes and devices are usually not covered for other pathologies--such as rheumatoid arthritis, although this will vary between carriers. Places like PW Minor and Drew Shoe company(both of whom are distributors for places like Hangar) cater specifically to these kinds of patients and are well-versed in getting products covered by insurance companies. We, as an office, do not deal with this directly, but let patients know that these services may be an out-of-pocket expense.
Functional devices are useful for patients with a mechanical problem--i.e. plantar fasciitis, hallux limitus. We use several different kinds. There are prefabricated orthotics of myriad type, many of which are moldable and adjustable. We carry some of these in our office. These work very well for people who do not have a very high arch or a very low arch. Patients with severe pes planus or cavus tend to do much better with a custom devices, casted with plaster or Biofoam. Both prefab and custom devices can last several years and can be recovered with Spenco or leather--we do this in our office. The negative casts we take are sent out to a lab that specializes in creating orthotics. There are several labs throughout the country which do this. Turnaround time is about 3-4 weeks. Most insurance companies do NOT pay for these at all.
SHOES: There are several instances in which we try therapeutic shoes. If a patient has a deformity which does not allow fit in a traditional shoe, they must be placed in a custom shoes. I am referring to patients with
I also would consider these in a patient who is not a candidate for surgery, but may have other pedal deformities, such as a severe bunion. A plastazote or poron orthotic would also be appropriate.
Extra-depth shoes are a good option for someone with hammertoes, bunions, calluses, pre-ulcerative lesions or also for a diabetic with LOPS or decreased sensation. These are often more aesthetically pleasing than a custom-molded shoe and have room for an orthotic if the need arises.
For any of these options for shoegear or orthotics prescribed outside of the office, we just write a prescription, which the patient can take to an orthotist. They do not need a referral per se. VA systems work on a similar basis. Cost for these can vary considerably. Pre-fabricated orthoses can run from $40-150, custom orthotics $110-$350. Shoes are $100+(the sky’s the limit). Medicare sets specific guidelines which we notify the patient of prior to initiating treatment, so there isn’t much room for argument there.
I certainly hope this answered your thoughtful questions. Again, if you have more questions or would like to stop by the office, do not hesitate to contact me via phone at Columbia Podiatry 573-443-2015. Thanks again. Good luck to you.
Kindest Regards,
Marianne J. Misiewicz, DPM