Why Are SCFOs Overlooked in the Pedorthic and Orthotic Communities?
August 2015 Issue
We've all had them. In fact, my staff and I encounter them weekly, if not daily. You know-that patient who needs more support and control than a foot orthosis alone can provide but for whom an AFO is overkill. What about a University of California Biomechanics Laboratory (UCBL) insert? In 40 years of practice, I'd bet that for every patient I've come across who actually liked his or her UCBL, I had ten others who found it to be terribly uncomfortable and therefore refused to wear it. This is where subtalar-control foot orthoses (SCFOs) come in to save the day.
By definition, an SCFO is a subtalar joint control device. It is typically a supramalleolar device whose proximal trim lines do not extend past the musculotendinous junction of the gastrocnemius and the Achilles tendon. It is designed to manage the function of the foot's anatomy by primarily controlling the range of motion of the subtalar joint, and many styles of SCFOs perform wonderfully in this capacity.
So often, we see a patient with stage I posterior tibial tendinitis who has been treated with a medially posted foot orthosis. In conjunction with a motion-control shoe, that approach is sometimes effective. But many times it is not enough, and the physician and orthotic practitioner elect to transition the patient to an AFO. Then, predictably, the patient finds the device to be too heavy, too bulky, too difficult to fit in standard shoes, and far too restrictive. So, either it ends up collecting dust in the back of the closet or the patient wears it begrudgingly and won't be coming back to see you again. There is no reason to lock the ankle in the sagittal plane to treat posterior tibial tendinitis.
In 2006, Alvarez et al. published a treatment protocol for stages I and II posterior tibial tendon dysfunction that has since been adopted by countless orthopedists and physical therapists across the country.1 The brace used in their study, and that they advocate in the article, was actually an SCFO. They recommended a custom, Marzano-style, short, articulated AFO-a brace that does not restrict sagittal plane motion whatsoever. There are all sorts of braces, custom and prefabricated, that would fit the bill for many of these patients. Shorter molded leather and plastic SCFOs, like an Arizona Brace with a standard length footplate would also work well, whereas a Wilson Janisse Group Hindfoot Restraint Brace (HRB) would prohibit ankle dorsiflexion and plantarflexion even less. Articulated Richie Braces are an option for these patients as well. The bottom line is that the patient with early posterior tibial tendinitis doesn't need an AFO that extends two-thirds of the way up his or her lower leg.
Pedorthists who are certified by the American Board for Certification in Orthotics, Prosthetics and Pedorthics Accreditation (BOC) can evaluate for, fabricate, and fit SCFOs under their scopes of practice. Of course, state licensing regulations and restrictions take precedence over what a practitioner's individual scope of practice may be as outlined by the certifying body. For example, in Texas, certified pedorthists are excluded from providing SCFOs. It is up to each practitioner to know the pedorthic scope of practice, and any restrictions beyond those outlined by the practitioner's certifying body, set forth by his or her state's OP&P licensing board.
An SCFO can be used effectively to treat virtually any condition that falls within the pedorthic scope of practice in which more control is needed than a foot orthosis provides. It is important to remember that SCFOs primarily provide coronal plane restriction. Some styles of SCFOs do provide minimal sagittal plane control. When creating your patient's treatment plan, it is important to remember that studies show that unless the patient wears it with a shoe, most SCFOs provide little in the way of transverse plane control.
Problems that can be addressed with SCFOs include posterior tibial tendinitis, posterior tibial tendon dysfunction (I and II), sinus tarsi pain associated with an acquired pes planovalgus deformity, peroneal tendinitis, painful subtalar joint osteoarthritis, talonavicular arthritis, and tarsal coalitions. SCFOs can also be used to provide more support to splint the midfoot for problems like tarsometatarsal joint osteoarthritis or a healing Lisfranc injury. In looking over the conditions listed above, you will observe that none of them necessarily requires triplanar motion control.
Patients appreciate being able to use a smaller, lighter-weight device that allows them to wear a wider variety of footwear. In fact, some devices can even be used with sandals. I have always been a firm believer in a minimalist approach to bracing. When a device is so obviously overkill that the patient knows it, he or she tends to shop around for something more user-friendly.
From a dollars-and-cents standpoint, many SCFOs bill out well, especially supramalleolar AFOs. Of course, if you're choosing to go with the overkill device simply because it bills out more, you're on your own. I think every ethical pedorthist, orthotist, or business owner frequently leaves a few dollars on the table when it is the right thing to do for the patient.
In summary, SCFOs can be, and often are, invaluable tools for not only resolving foot pain but also for increasing patient compliance and satisfaction. SCFOs can be worn in many different shoe types into which traditional AFOs would never fit. Patients enjoy the more streamlined fit of SCFOs. There are many fabrication companies that offer several different custom SCFO designs as well as larger manufacturers that provide myriad prefabricated options. SCFOs are the perfect filler for that void between a custom foot orthosis and a full-blown, traditional, restrictive AFO. In most states, a board-certified pedorthist is well within his or her scope of practice to provide SCFOs. If you're not currently providing patients with SCFOs, take the time to educate yourself about what is available and how to use them. Adding SCFOs to your arsenal of treatment options will greatly enhance your standing with your referring physicians and is practically guaranteed to produce more happy patients.
Dennis Janisse, CPed, is president and CEO of National Pedorthic Services, headquartered in Milwaukee, Wisconsin. He is also a clinical assistant professor in the Department of Physical Medicine and Rehabilitation at the Medical College of Wisconsin, Milwaukee, and clinical director of Pedorthics for OHI, Ronkonkoma, New York.
- Alvarez, R. G., A. Marini, C. Schmitt, and C. L. Saltzman. 2006. Stage I and II posterior tibial tendon dysfunction treated by a structured nonoperative management protocol: An orthosis and exercise program. Foot & Ankle International 27 (1):2-8.