Noah: Welcome to DC2Be Revolution. Helping chiropractic students think big in order to live large. I’m your host Noah Volz and today I’m here with Dr. David Wedemeyer. He's a chiropractor and a certified pedorthist who created Sole Solutions lab to create a uniform standard in orthotic dispensing among allied health fields. What is a pedorthist and why did you become one?
Dr. Wedemeyer: I started my practice in Newport Beach, California and right away I started looking at gait and feet. Back in 2000 there was no road map for a guy like me. I made friends with podiatrists and started learning from them. I didn’t have a lot of time until work comp failed. Then I started looking more and more into orthotics in the industry and found out that there was a program called the Medicare diabetic therapeutic shoe bill. It takes at-risk diabetics with uncontrolled type 2 diabetes and helps them find footwear solutions. No one knew this at the time but Medicare's rules allowed someone with a little bit of training to become a supplier. I went to the local Foot and Ankle orthopedist and started getting referrals to supply these patients with the proper insoles.
I was the first and only chiropractor to serve this program and I did very well financially until they closed the loophole and chiropractors were no longer allowed to participate. They showed up at my office and asked for three files, looked at the files and left without any corrective action so I kept doing it. In 2007 I took the course where I put in a thousand hours of lab time: grinding orthotics, cutting shoes apart and more. I secured my pedorthist certificate. That is someone who is trained to evaluate the foot and ankle, evaluate gait, evaluate for orthotics.
Noah: Thank you. What is the standard examination that somebody could expect when being fitted for an orthotic?
Dr. Wedemeyer: Well, what I've done is my lab and you have to understand when we opened Sole Solutions. Chiropractors, we’re really not trained to do a foot and ankle examination. Most company’s exam consists of standing on a platform and taking a 2D image. That’s not the standard in the industry. Our examination we look for range of motion of the ankle joint, range of motion of the first ray with and without weight bearing.
Looking at the calcaneus with and without weight bearing. Once you understand the timing of gait and what muscles are being used to produce that motion it becomes very easy to note dysfunction and then you can apply that to the orthotic.
Pronation is a very normal part of gait that occurs with loading the subtalar joints.
If the foot rolls in everything else goes with it.
The bottom line is why do they have a really flat foot? I have a sheet chiropractors can go through that they take certain pictures of the foot and a gait video.
We go over it together and I help them decide on what they need and using that formula. One of the big problems in the industry is comfort.
We don’t get very many returns because through this process they’ve already filled out the prescription and that’s the distinction. If they understand what they need based on the patient’s needs then the patient gets what they need.
Noah: Can you give some examples of these prescription variables?
Dr. Wedemeyer: I use a cast of plaster or pop cast. Most chiropractors are familiar with a foam box cast. If you look inside one of these casts there’s no arch in there, which is typical of a stand in the box cast. I use a pop cast because most of my patients are sent by podiatrists or orthopedic surgeons who just don't do that they're busy with other things.
The advantages to a pop cast, by the way this will be replaced soon with a laser that will digitally build a mold, is that it gives a broader picture of the foot anatomy.
If they stood in a box you wouldn’t see the complete picture. You see the foot rolling in, but if you look at her from the rear and her toes are abducted and you’re looking at the attitude of the heel when their standing and the pronation of the arch.
So the orthopedist sends her over and asks for my advice. They never give me a script, they just rely on me to do it.
In the old days you take that pop cast pour plaster into this cast, peel it off, and add a little expansion or add little bit of plaster to allow for some lowering of the medial arch. Now it’s done digitally.
We put that on the screen manage that motion or the attitude of the foot.
Kevin Kirby taught me most of what I know.
He's someone that has been my mentor and friend and supported me. Who imagined podiatrists coming in to a chiropractor lab owner?
Kirby has taught at the California Podiatric Medical College for a long time and he created something called a medial heal. What they do is they shave down an angle instead of a post. This is a typical rear foot post which adds stability in the frontal plane.
You cut this at an angle now you have this dent in the cast or digitally on the screen. When you mold plastic over that or graphite, usually it’s heat molded in a vacuum press.
It’s really clever because it's more comfortable and well tolerated.
You have this modification inside the shell of the orthotic that's like a bump and it resists the motion of the medial arch.
There's a lot of different modifications that we might do on an orthotic. Also, there’s something called Morton's toe and it's present in about 18% of the population where the second metatarsal is longer than the first.
This can be problematic because they're prone to bunions.
When the foots on the ground you can't get this.
This goes back to the exam. Is the foot able to get forty to sixty degrees of dorsiflexion? When you roll off the foot into toe off you have a flexible MTP joint.
People with a Morton's toe have a lot of pain because all the weight is shifted laterally to the second MTP joint and you get a lot of callouses here.
The bottom line is a rectangular-shaped extension that’s put into the top cover and it raises or puts a forced dorsal force into the first MTP joint and opens it up.
Noah: What is the level of customization in orthotics and how can consumers differentiate between those different levels of customization?
Dr. Wedemeyer: There’s a gentleman named Craig Payne who is well known in podiatry who discusses this lately in a big podiatric publication. Over-the-counter orthotics like super feet have a library.
All labs have a library which simply means you’re taking or scanning feet and collecting a library of shapes. There's pre-fabricated. They have a role and help people every day. There's a lot of great over-the-counter orthotics out there.
Then you have a mid-level where they're calling it custom. This is what Craig Payne talks about in his article. They're not truly custom. What we do is take the cast scan that's unique to that person’s anatomy and foot and then customizing the way that you want it based on pathology you are trying to solve.
Some labs are using libraries. They are taking shells off a shelf that are very similar to the patient and matching it up. They are customized and not custom. If you’re paying $100 or more for a lab to produce an orthotic it should be custom.
I think it's dishonest to say custom and then give someone something that’s customized.
Noah: What is the cost for each different variation?
Dr. Wedemeyer: I can tell people what I charge or what we bill insurance. Most prefabs will probably be about $50 or under. Any companies that are producing orthotics at a cost to chiropractors under 100 dollars are typically customized because it's very difficult to go through this process.
The giant in our industry charges a hundred and fifty to two hundred dollars and I think that’s high because they're using a very small layer of ethyl vinyl acetate it’s the stuff on the bottom of your running shoes.
We make an orthotic that's a hybrid that has multiple layers. The bottom line you have something with varying rigidity depending on what the patient needs.
Other companies use the same materials we use to fill the base and we use a more expensive, high quality, well-built orthotic made out of many materials. That's why this stuff gets expensive.
I basically work to understand the foot in certain stages of gait.
Especially when all of the weight is supported on one foot.
Noah: When is a custom orthotic indicated and when are prefabs fine?
Dr. Wedemeyer: The most common pathologic foot condition is plantar fasciitis. With a condition like plantar fasciitis I do something called Lodi taping. It is a method that provides a major amount of support to that medial arch of the foot. If I Lodi tape them and they get immediate results I know that they need support and then I provide that with their footgear.
It comes down to the rationale. They may need support so I decide if it needs to be over the counter or custom. When I see a pathological condition of the foot that’s when I use a custom. If you look at their feet and try over-the-counter for more support and it doesn’t work then look at it again, make sure you didn't miss things and develop a new rationale.
Most of your patients don’t need custom orthotic.
Noah: if somebody's been diagnosed with plantar fasciitis and your thinking that they need more of a custom thing how do you know?
Dr. Wedemeyer: Insurance needs a diagnosis to meet medical necessity. They’ll cover orthopedic shoes for certain conditions.
Those foot scanners that you stand on when you open it up it’s a HP LaserJet black-and-white scanner and with those systems the only thing you can get is a length and width. You can’t get topography so it’s an extrapolation.
I know the guy that wrote their software and I was shocked because you’re taking a full weight bearing two-dimensional scan and insurance won’t cover it because its not useful.
I know someone that scanned a hand and got an orthotic back from that company. They’re reproducing the same device over and over.
Orthotics were meant to treat pathology.
We no longer think that orthotics just change architecture and hold your foot in a position, but they work on kinetic motion. As you roll over the foot from heel strike into loading you’re hitting the orthotic and it’s influencing your gait and we can change those parameters if we know what to do.
See the full interview here: https://youtu.be/oJ9EqxtTI-A
Writing with originality, generosity, compassion and purpose, Dr. Noah Volz imparts valuable lessons in an entertaining, engaging and snappy way―backed by a wealth of experience. As an author, chiropractor, and entrepreneur, he has started and run multiple companies and has been the host of the DC2Be Revolution YouTube channel and podcast.