Orthotics Out of Pocket
ORTHOTICS
Adam Rodnick
DC
Custom orthotics are an important part of my practice. Most importantly, I use custom orthotics to improve my patients’ neuromusculoskeletal health by changing biomechanical abnormalities, which could lead to premature degenerative changes. I use them to help prevent injuries from athletics, but I also use them to help in structural correction and treating injuries.
However, for my practice, they’re also a nice service line and, in turn, an important part of the practice. When I mention to my colleagues that I prescribe and dispense orthotics to my patients, I often hear different responses. I often hear things such as, “I thought about doing orthotics, but insurance doesn’t pay for them.” That’s one of the most common things I hear from other chiropractors when considering using custom orthotics in their practices. Most patients who receive custom orthotics in my practice don’t have coverage for them but happily pay for them out of pocket. Of course, we do attempt to verify coverage, if applicable, but most carriers have little to no coverage in my state. When patients understand the profound benefits of custom orthotics in conjunction with their chiropractic care, they have no problem paying for them. The benefits significantly outweigh the costs, and, if properly explained, pricing shouldn’t be a hurdle at all.
A recent review of literature showed that custom foot orthoses were found to reduce spinal curves in juvenile patients with mild idiopathic scoliosis and concomitant abnormal foot biomechanics.1 Every chiropractor will have a moment when they’re showing X-rays to parents of a child with scoliosis who have already seen a pediatric orthopedist. The orthopedist said the child is not surgical, but that she should be monitored. The child has pain and an altered gait and posture. I’m the biggest advocate for the chiropractic adjustment you can find, but I can’t follow a child around 24/7 and adjust her every time she takes a few steps. Her custom orthotics can follow her wherever she goes, though, to help maintain her biomechanics while she’s weight-bearing.
In my clinic, we would measure the scoliotic curve with our digital X-rays and measure the femur head discrepancy. I would perform and review a digital foot scan as well as physically assess the Q angle, pelvic alignment, and foot pronation. For most parents, it would be a no-brainer to purchase custom orthotics for their child. When the orthotics arrive, we would have the child wear them, take a follow-up X-ray, and, most of the time, the scoliotic curve decreases immediately. I may also add a heel lift to the side of the low femur head measured to the millimeter. This is just one small example of how I’ve used custom orthotics in my clinic.
The World Health Organization states that musculoskeletal conditions are the leading contributor to disability worldwide, with low back pain being the single leading cause of disability globally. The more we as Chiropractors can do to prevent the development of osteoarthritis by improving overall biomechanics the better. Not every patient in my clinic is a candidate for or chooses to purchase orthotics but I feel that if they are a candidate and I don’t offer them the option I’m doing them a disservice. Sport and exerciserelated injuries are associated with obesity, reduced quality of life, and post traumatic osteoarthritis. Youth who suffer a sport-related knee injury demonstrate higher total body and abdominal adiposity within 3-10 years following injury than uninjured controls.2
"I've chosen to incorporate a digital foot scan into my initial examination and biomechanical analysis of my patients."
I see a lot of high-level athletes in my clinic. Not only do I do everything I can to keep them performing at their optimum, but I try to help them prevent injuries and treat the injuries they sustain. I recently saw a young woman who participated in competitive cheer at a world class level. She presented with low back pain and significant tenderness and pain in one foot. She came in with a walking boot that she was told to wear by a physician. Her parents wanted to know if she could participate in cheer or not. They showed me the level of aerial maneuvers that she did in practice and competition. After my thorough examination, x-rays, and digital foot scan I made a few recommendations and gave a few options to the patient and her parents. I always want to get to the bottom of what’s causing the overall pathology, dysfunction, or symptoms. Her pelvis and femur heads were significantly even as seen in x-ray, she had significant pronation and quadriceps femoral angle or Q angle as seen in examination and collapsed lateral and transverse longitudinal arches as seen in the digital foot scan.
Although this gave me a lot of information about causality and potential treatment it didn’t give me everything. I needed to let the parents know if she could participate in cheer or not and if not for how long. I let her parents know that to really make those calls I would like to order an MRI as I suspected a possible repetitive trauma stress fracture or bone marrow edema. Unfortunately, the managed care prior authorization process for obtaining advance imaging as well as the pressure to forgo plain film radiographs can be a risk factor for improper diagnosis and treatment in these cases. The parents were happy to pay out of pocket for the MRI and the results showed bone marrow edema in the talar dome. I advised them to discontinue the boot, use crutches and stay off it for a few weeks while staying out of cheer as to not risk fracture and injury for the rest of the season and the world championship. We began lumbar and pelvic adjustments, lower level laser and KT taping for the foot, and prescribed custom orthotics for her to wear when I felt she should bear weight. Flexible orthotics significantly improve the Q angle with hyper-pronating patients,3 and we could visibly see it immediately when this young lady put them in. A few weeks later she was feeling significantly better and they asked if she could participate again. The only way to know for sure would be follow up advanced imaging. No more marrow edema on the follow up MRI and she returned to activity with no problems. The parents were extremely happy with how thorough my clinic was and with the orthotics for her to wear going forward.
I’ve chosen to incorporate a digital foot scan into my initial examination and biomechanical analysis of my patients. By doing a thorough biomechanical assessment the need for orthotics sells itself when patients can visually see abnormal loading of their joints and tissues through objective measures, regardless of their coverage. Many patients, especially athletes, will ask me what they can do to improve their structure when looking at the results of a digital foot scan and x-rays. They may ask what they can do rather than what I can do, before I even make a recommendation once they can see and understand the objective biomechanical faults they have. Most people want something they can do for themselves, not only what we can do for them. Wearing custom orthotics is something they can do for themselves every single day to work on their musculoskeletal health. It’s not only something they can do, it’s a very easy thing to do, especially when compared to other active care recommendations that any chiropractor, physical therapist or medical specialist may recommend. I make orthotics part of my recommendations and treatment plan when they’re appropriate and medically necessary, regardless of their insurance coverage. It is important to be knowledgeable about verifying coverage for and coding for orthotics and to do it regularly but when the patients are properly educated, they will pay out of pocket. We generally collect at least half up front before we order from the lab to cover most of our costs, which patients are happy to cooperate with as that’s common with most custom products. When used properly clinically orthotics can be an important part of the patients care and an important part of the business of your practice.
References
1. Rothschild, D et al: Indications of sole lift and foot orthoses in the management of mild idiopathic scoliosis—a review. J Phys Ther Sci. 2020 Mar; 32(3): 251-256.
2. C.M. Toomey, J.L. Whittaker, A. Nett el-Aguirre, et al. Higher fat mass is associated with a history of knee injury in youth sport. J Orthop Sports Phys Ther, 47 (2) (2017), pp. 80-87
3. Kuhn, DR et al: Immediate changes in the quadriceps femoris angle after insertion of an orthotic device. J Manipulative Physiol Ther 2002 Sep;25(7):465-470.
Dr. Adam Rodnick practices at Rodnick Chiropractic in Commerce Township, Michigan. Dr. Rodnick is a 2006 graduate of Life University.
