This soft-spoken, slim and impeccably dressed woman presented with a distress level at best in fragile control. She’d had six months’ increasing pain in her knees and feet which by now had taken her walking away. This was the activity she loved, and it kept her fit and happy. Though she was 24 years my senior (and I graduated college in 1971), I felt strong fatherly instincts kick in after she told me her story.
She’d used one pair of orthotics successfully for over thirty years. Although she’d had many lower extremity pains prior to receiving the orthotics, all pains went away shortly after she began using them. She could not recall what those pains were when I questioned her. The problem was she no longer had the orthotics. Six months prior to visiting me, she’d visited a podiatrist for a splinter, which he successfully removed. But he noticed her orthotics, and emphatically suggested she let him make new ones. She said she’d been pleased with them, despite their looking old. They weren’t falling apart or broken in any way. He said she needed new ones because the pair she had was so old. After she acceded, he took her old orthotics away, saying the lab would need them to make the new pair. When he gave her the new orthoses, she asked also for her original ones back. He told her the lab had thrown them away.
The orthoses he gave her looked nothing like her old pair. Knee and foot pains started after she began using the new orthotics. He said he was sorry, but he couldn’t help her. She then visited four subsequent podiatrists, and spent nearly $3,800 in the following months for orthotics and doctor visits. She was depressed. For the first time she indeed felt like "someone in her 80s."
I was determined to figure out what those old orthotics looked like so I could provide her with copies as quickly as the lab could provide. Even though she couldn’t recall what the old ones looked like, I thought I might be able to piece a prescription together combining her vague recollections of their character and my asking the right questions. She brought her 5 new pairs of orthotics in a zip lock bag. She wasn’t wearing any of them. She could recall that her old orthotics were of a different material and fit much more easily in her shoes). This led me to think rigid orthotics, not flexible like the ones she brought in.
She said the arches of all her new orthotics were uncomfortable and she often had to take them out of her shoes as the day went on. This usually means the arches of orthotics are too high; when I measured her q-angles (standing kneecap alignment) I found that only a certain foot position would hold her knees in good alignment. Too high or too low of an arch left her in poor alignment. OK, good. Now I knew both the material and the arch height. She’d mentioned they’d fit easily in her shoes, so I surmised they were 3/4 length, not full length like her current pairs. Since she now had pain at the balls of her feet, a typical pain associated with her long-term bunions, I figured those orthotics had metatarsal pads on them, which are bumps on the top surface of the orthotic which were especially in vogue 30 years ago and used to help forefoot pain.
So now I had the material, the length, the arch correction, and the forefoot correction. Every orthotic made in those days had a 3-degree rearfoot wedge, so I Rxed that as well. All I had to do was cast her in the correct arch position, and write the prescription. Ironic that a podiatrist who prides himself on non-boilerplate orthotics was counting on what I’d arrived upon as one of the most cookie-cutter prescriptions I’d ever written to solve this problem.
I asked the lab to rush the orthotics, which I dispensed to her in a week. Her initial response, something I’ve learned to watch like a hawk when I first observe a patient try custom orthotics, was favorable. "They feel familiar," and the slightest hint of her smile graced me. She called me a week later, saying 60% of her pains were gone. One month later she called, as I’d asked her to do, and she simply said to me, "Thank you, doctor, I feel young again."