Functional assessment’s role in orthotic implementation

A custom, flexible orthotic assists the foot through a normal gait cycle. It embraces the 26 bones, 33 joints and more than 100 muscles, tendons and ligaments to help them perform within their standard biomechanical functions. A custom orthotic restores the foot’s normal motion compared to a more rigid orthotic that arrests normal joint mobility and can alter muscle function. Deciding which type of orthotic works best for your patient begins with a comprehensive history and exam, but also needs to include some functional assessment tools. 

There is much discussion about the right time to place orthotics, what type of orthotic is best and how many hours per day the patient should wear them. However, a critical aspect of placing the correct orthotic is adequately evaluating the patient in order to decide which orthotic will provide the best outcome. This aspect of orthotic placement is an integral part of the patient’s success and is easily determined during the patient visit. 

Below are some ways to evaluate a patient’s need for custom, flexible orthotics in practice. Depending on the complexity of the case and patient, you may do any or all of these. An excellent first step is to scan the patient’s feet either with digital technology or with a simple visual scan. Additionally, you should evaluate the functionality of the foot muscles and joints. How are the muscles, joints, tendons and ligaments performing? Each step in this process guides the DC in the decisions of orthotic selection. 

Step one

A comprehensive history is always the best way to gather facts about previous orthotic use and musculoskeletal conditions. To understand the emerging research on the kinetic chain, we must first understand the foot’s connection to the body’s biomechanical capabilities or faults. This begins with understanding the patient’s history of injury. 

Step two

Physical exam of the region of complaint includes a static postural exam looking at the frontal and sagittal planes of the patient (front/back and side views). This step lets us see a snapshot of the patient’s kinetic chain. We will look at musculoskeletal use or disuse patterns, muscle atrophy or hypertrophy and alignment. Starting from the pelvis and moving superior sets the stage for what you find in the hips, knees, ankles and feet. For example, Figure 1 shows a patient with the typical fault pattern: a weak right glute and winging of the medial border of the left scapula. Static postural exams can reveal a lot about the patient’s functional kinetic chain usage patterns. By looking at the frontal and sagittal planes, the DC can see the patient’s demands on the body.  

Calluses don’t lie. Therefore, examining feet, footwear and use patterns is a big part of unlocking the kinetic chain and getting to the actual resolution of many musculoskeletal complaints.  

Step three

This step consists of a navicular drop test, squat test, jump, landing error scoring system (LESS) test, gait analysis and any pertinent sports-specific tasks. These tests can be optional, or one may pick the test(s) that apply to the patient; however, some functional assessment is advised if you are working with athletes or active individuals. 

The navicular drop test is a relatively simple test that looks at the navicular height in a non-weight-bearing state by marking the navicular tubercle with the patient seated and then reassessing the navicular height with the patient in the standing position. This test tells the DC about the extent of the fall of the medial longitudinal arch when standing and during the gait cycle.  

Squat test

If a patient is active and can safely perform the squat test, this can give the DC information on movement patterns, faulty patterns and regions of tightness or dysfunction in the ankle, knees, hips, lower back, upper back and shoulders. The squat is a quickly instituted movement that lets you glean all kinds of information on how the musculoskeletal system is functioning or dysfunctioning as a total unit. The following is a list of items to notice as the patient moves into a squat and rises back out of the squat: 

• The parallel relationship between the back and tibia 
• Knee position (valgus or varus) 
• Anterior knee position in line with or posterior to the toes 
• Upright back and chest position 
• Heels firmly on the floor for the duration of the movement 

LESS test

This test is fantastic for the athletic or active individual to prevent injury in the lower limb. Performing this test can give information on predisposition to anterior cruciate ligament (ACL) rupture, which is particularly important in athletics today. This test involves having the patient jump off a raised block and land. The DC watches the landing pattern, particularly the optimal knee-over-toe position, compared to the valgus landing position in those predisposed to an ACL rupture. 

Gait analysis

Having the patient walk or run provides essential information, pulling together all the information you have gathered in the physical exam, static postural exam and the tests mentioned above. At this point, you can evaluate how the patient uses the body in forward locomotion. Essentially, how does the musculoskeletal system work together in the action of forward locomotion? The stance phase is 60% of the gait cycle that pulls together most of the big muscle activity in the lower limb and can speak to intraarticular and extraarticular integrity. The swing phase is the non-weight-bearing phase of gait in which the leg swings through to prepare for the next gait cycle. 

Final thoughts

In conclusion, placing the correct orthotic is vital in sealing the patient’s treatment with long-term support. This enables the adjustment to better hold in addition to correcting leg length inequalities. Adding a few extra steps to the exam gives the DC tremendous clinical data to support the need and type of functional orthotic that may work best for the patient. A custom, flexible orthotic provides support without limiting the foot in any plane of motion. This allows the foot’s intrinsic muscle to work and gain strength along the proper force vectors with each step. 

CHRISTINE FOSS, DC, MS.Ed, ATC, DACBSP, DACRB, ICSC, has a master’s degree in sports medicine from Old Dominion University and is currently director and lead instructor of the Northeast College of Health Sciences Certified Chiropractic Sports Physician program, Education Chair for Federation Internationale de Chiropractique du Sport and Director of Education for Foot Levelers. She has worked with Team USA track and field, men’s gymnastics and at the World Games as a medical staff member. She can be reached at drcfoss@gmail.com or @drchristinefoss on Instagram.