Optimizing Foot Care through Pedorthic/Podiatric Partnerships
November 2012 Issue
As with any intricate piece of equipment with many moving parts, the human foot is subject to a wide array of possible malfunctions-ranging from congenital deformity and improper gait to partial foot amputation-as the result of trauma or systemic disease such as diabetes. Whatever the cause, the result is pain and reduced locomotion.
Pedorthists and podiatrists are both trained to help patients overcome foot pain. As physicians, podiatrists can diagnose medical conditions in the entire lower limb and perform appropriate interventions. As professionals trained in the biomechanics of the foot and ankle, pedorthists understand how to build shoes and appliances that alleviate symptoms and correct foot and ankle pathologies.
Podiatrists routinely write prescriptions for footwear and devices that pedorthists are ideally qualified to provide; however, more and more allied healthcare professionals from outside the field are seeing the benefit of getting a foot in the door, so to speak. Physical therapists, chiropractors, and even athletic trainers can now provide prefabricated devices to help relieve foot pain, creating more competition-and confusion-in an already competitive field. The challenge for the pedorthic profession is to develop a more symbiotic relationship with podiatrists so that the two can work together seamlessly to provide optimal outcomes for patients in need of foot care.
One step the pedorthic profession has already taken to help ensure that they are the go-to professional when it comes to foot care and foot care products is increasing its professional educational requirements. On January 1, 2013, a four- to six-month program of study will replace the current two- to four-week training course as the minimum educational requirement to sit for a certified pedorthist credentialing exam.
How pedorthists and podiatrists collaborate now and in the future depends on how pedorthists choose to manage their careers.
Three Kinds of Pedorthists
Pedorthics is concerned with the care of the foot and ankle through the use of foot orthoses, footwear, and other related devices and modifications. According to the American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABC) Pedorthic Scope of Practice, "A prescription is required for any pedorthic device, modification, and/or prefabricated below the knee orthosis addressing a medical condition that originates at the ankle or below." With a scope of practice limited to the ankle and below, pedorthists generally gravitate toward three employment paths.
(1) Professional Shoe Fitter/Provider
Since the days when they were referred to as orthopedic shoemakers, one option for pedorthists has been professional shoe fitting and the retail sale of orthopedic and comfort shoes. In fact, Robert Schwartz, CPed, president and CEO of Eneslow Pedorthic Enterprises, New York, New York, insists he does not have a practice; he has a retail pedorthic shoe business-one that has been making and selling shoes for more than a century.
Among his 45 employees, Schwartz has 15 certified pedorthists who work on one of two sides of his business: retail, which provides well-fitting shoes directly to customers; and custom orthopedics, which provides devices and care for patients with complex foot disorders or who need post-surgical foot care.
"Podiatrists usually send us their leftovers, patients they don't want to deal with, and we take them with a smile on our face because we know we can help them," Schwartz says. "We also take care of...people who know that the right shoe makes a difference."
Skilled pedorthists are knowledgeable about shoes as well as the range of available orthotic options and can build a good-looking shoe that accommodates whatever appliance is needed, Schwartz says. "We can even make six-inch platform heels more comfortable for the fashionista," he adds.
Fashion aside, there seems to be a trend toward more and more athletic footwear stores adding pedorthists to their fitting staffs to serve the growing fitness market that is concerned with proper exercise biomechanics.
"A well-stocked shoe store is valuable to foot and ankle practitioners regardless of the specialty," says Pam Haig, CPed, vice president and founder of The Robert M. Palmer, M.D., Institute of Biomechanics, Elwood, Indiana.
(2) Clinically Oriented Pedorthist
On the other end of the spectrum are pedorthists who want to concentrate on fabricating custom corrective products for other healthcare professionals.
According to Haig, a well-trained pedorthist can apply biomechanical principles to products such as inserts, orthoses, shoes, or shoe modifications to help patients avoid surgery. They can also use their knowledge to augment the healing process after foot surgery and, working in conjunction with the podiatrist, can help to develop alternative treatment options.
"It's important that [the pedorthist and podiatrist] are working together to resolve chronic, unresolved foot pathologies as a team," she adds.
The clinically oriented pedorthist will often become an employee of a podiatrist, creating custom shoes and appliances exclusively for that practice. "It can be a mutually beneficial relationship," Haig says. "The podiatrist gets a skilled practitioner to share the patient load, and the pedorthist has someone to share overhead expenses and management of the business, as well as having an on-site consultant/mentor."
(3) Independent Pedorthic Practitioner
There are also pedorthists who want to own their own practice and receive referrals from a variety of sources. They can work through a pharmacy, sublease space within a podiatrist's or orthopedist's office, Haig says, or join with orthotists and prosthetists to provide full-service OP&P care.
Louis J. DeCaro, DPM, owner of DeCaro Total Foot Care Center, West Hatfield, Massachusetts, has been in practice since 2002. He does not employ a pedorthist in his primarily pediatric practice; however, he holds regular biomechanical gait analysis clinics where a range of related health professionals, including a certified pedorthist, perform patient evaluations. DeCaro includes the intake of family history as part of the clinic.
"Patients will come in for orthotics for a foot problem, but the history tells me hip problems run in the family," DeCaro explains. "Specialists they had seen before never looked at the feet, where the hip pain originated. It's important to correct the foot problem as early as possible, so in the clinic I can write a prescription for the pedorthist on the spot."
DeCaro says his training at Barry University School of Podiatric Medicine, Miami Shores, Florida, included some "abstract" biomechanical theory, but the emphasis was on surgery. He became deeply interested in applied biomechanics in 2005, when he met Joe Coletta, CPed, and Roberta Nole, MA, PT, CPed, who were working on a system of foot typing to create better-fitting foot orthoses. (Author's note: DeCaro and Nole now own NolarO24, Middlebury, Connecticut, which provides QUADRASTEP and littleSTEPS patented, prefabricated foot orthoses, based on the foot typing system Nole and DeCaro developed. Coletta is the director of education.)
Working on the NolarO24 product line "really opened my eyes to see what proper biomechanics could do for my patients," Nole says. "I'm not a territorial practitioner. I think there should be greater collaboration between all medical professionals. Why not put all our heads together for a better outcome for the patient?"
Outside Forces at Work
Conditions are ripe for pedorthic/podiatric partnerships to develop and thrive. In addition to increasing competition from other practitioners-not to mention individuals who get professional shoe fitting advice and then purchase shoes online- the number of patients who need foot care is rapidly increasing. The number of persons in the United States aged 65 or older is growing, the incidence of diabetes and obesity is rising, and more veterans are returning from active duty with lowerlimb injuries. Combining the podiatrist's medical knowledge and the pedorthist's biomechanical skills as part of an overall foot care treatment plan can help to ensure that each patient receives the appropriate level of care.
There are also regulatory forces at work that are affecting the entire OP&P landscape. In July, Pennsylvania became the 11th state in the nation to require licensure for prosthetists, orthotists, pedorthists, and orthotic fitters. The new law sets standards of professional conduct and requires practitioners to fulfill educational and training requirements. Similar laws are on the horizon in other states as well.
The new education standards for pedorthic certification will make it more challenging to earn a certified pedorthist credential. Many podiatrists opted to pursue a certified pedorthist credential as a result of the Medicare Therapeutic Shoe Bill (TSB) in 1993, Schwartz explains, because it allowed them to be reimbursed for fitting shoes for their diabetic patients themselves without having to write a prescription. Now, pedorthic education needed for certification will take an estimated five to six months to complete. It is difficult for most physicians to be away from their practices for that period of time, so podiatrists today are more likely to write a prescription for a custom shoe. Going forward, however, an individual who has already completed his or her pedorthic education and achieved pedorthic certification has an advantage to meet patients' foot care needs.
Adding to these forces is the ongoing reimbursement tug of war. The O&P profession, including pedorthists, is caught in conflict between Medicare and physicians over patient documentation. If the pedorthist does not get paid unless the referring podiatrist completes all of the paperwork, it is in the pedorthist's best interest to have a good working relationship with the physician who is writing the prescription.
In the end, however, the most compelling reason for closer collaboration between the pedorthist and the podiatrist is an improved outcome for the patient.
Neil Horsley, DPM, FACFAS, FASPS, FACFAOM, FAPWCA, CPed, is the department chair of podiatric surgery and applied biomechanics at the Dr. William M. Scholl College of Podiatric Medicine, North Chicago, Illinois. And while he also dispenses therapeutic shoes for his patients with diabetes in his private podiatric practice, he admits that he does not do the shoe modifications that can be crucial to reducing the risk of developing or exacerbating ulcers or infection. He always refers such accommodations to pedorthic providers in the community.
Horsley describes the relationship between podiatrists and pedorthists as a "beautiful" one. "I'm not a practicing pedorthist who owns a building filled with an inventory of shoes," he says, "but as a podiatrist, if my patient needs something more than just a therapeutic shoe, I know exactly who to send them to with a prescription to get what they do need."
Kate Hawthorne is a freelance writer living and working in Fort Collins, Colorado. She can be reached at