JUNE/JULY 2010 • PODIATRY MANAGEMENTwww.podiatrym.com 109

There is good news and badnews when it comes to footorthotics. The good news is

that more Americans are purchasingfoot orthotics to help alleviatepainful foot ailments than ever be-fore. The bad news is that they arenot getting them from podiatricphysicians. Where are Americans in-creasingly purchasing their foot or-thotics from? The answer is varied.Broadly, two main categories haveemerged; healthcare providers andretail foot health enterprises. Withineach of these there are many differ-ent groups or business types whichdispense “foot orthotics” to foot suf-fering patients. Sadly, podiatrists, the

early pioneers and developers of thisimportant therapeutic modality,have been steadily losing marketshare over the last two decades. Un-deniably, the fastest growing areawhere Americans are getting theirfoot devices is at retail.

Retail opportunities for “custom”foot orthotics encompass both thetraditional brick and mortar storesand many online ordering opportu-nities. While the podiatry-dispensedmarket for foot orthotics has re-mained relatively flat for a protractedperiod of time, the number of peoplegetting foot devices elsewhere hasbeen exploding over the past decade.These trends represent an incalcula-ble missed opportunity for podiatryand may portend even greater finan-

cial challenges in the future.It is not unthinkable that podia-

try may ultimately become a non-factor in the prescribing and dispens-ing of custom made foot orthotics.Certainly, the rapid explosion ofnon-podiatric alternatives for dis-pensed appliances would suggestthat podiatrists are becoming a lessand less important part of the pro-cess. Over the past several decades,the podiatric physician has evolvedto the very narrow end of the funnelfor people seeking pain relief fromfunctional orthotics. In sharp con-trast, just three decades ago, the po-diatry community enjoyed virtualexclusivity for these items. It hasbeen estimated that foot orthotics

By Jason Kraus

Continued on page 110

Retail CustomFoot Orthotics:

The Big OneThat Got

Away fromPodiatry?

Preserving thevalue of podiatry-

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treatment of many foot ailments anda burgeoning industry ready to sup-port practitioners, the podiatry mar-ket quickly became recognized as theleading experts in functional foot or-thotics. Laboratories like Langer, Inc.

began massive edu-cational efforts tohelp practitionersunderstand andapply the evolvingscience of biome-chanics. Other labsbegan springing upand emulated theearly model de-signed by Langer.Podiatrists weretaught comprehen-sive assessmenttechniques, pre-scription writing,proper casting andtrouble shootingapproaches. Labs

employed expert biomechanical con-sultants to assist DPMs with difficultor challenging patients. The result ofthis partnership between podiatristsand their laboratories helped to fur-ther the podiatric leadership positionin the world of functional foot or-thotics.

Millions of foot suffering patientswere being treated successfully bypodiatrists across the country whowere able to applythe principals thatwere being devel-oped and taught.There was almostno reimbursementfor these productsduring this time.Podiatrists werequite capable ofexplaining thebenefits of thesetherapeutic ap-proaches and hav-ing patients paytheir fees directly. The confidence in,and passion for, the beneficial resultsthat orthotics represented in podi-atric practices was easily conveyed tothe unknowing and skeptical uni-verse of patients.

Intellectual and EconomicChanges

Things began to change towardsthe second half of the 1980s. Someof the intellectual excitement began

produce several hundred million dol-lars of practice revenue for the podi-atric profession. Further erosion oforthotic dispensing should be acause for great con-cern. A review ofhow prescribedfunctional foot or-thotics evolved into“custom fit” archsupports might pro-vide clues into howto stop further attri-tion and offer in-sight into how toregain some of thelost relevance ofpodiatric interven-tions.

The Golden Ageof PodiatricBiomechanics

The functional foot orthotic ex-plosion can be traced back to the late1960’s and early 1970’s. At this timethere was a fortuitous conflating ofscientific knowledge and lifestylechanges. The knowledge leap waswhat became known as “podiatricbiomechanics” and was launchedinto the podiatric mainstream byMert Root, DPM, John Weed, DPM,Robert Hughes and William Orien,DPM through the publishing of theirseminal book, Biomechanical Evalua-tion of the Foot, Volume 1. These earlyvisionaries attracted other pioneersin their mission to present an inno-vative and coherent approach to thestudy of normal and abnormal func-tion of the feet. Dr. Root’s appliedorthotic techniques laid the ground-work for future developments andimprovements in foot orthotic thera-py. Some of their early disciples,such as Sheldon Langer, DPM be-came enthusiastic biomechanicalevangelicals and helped launch themodern foot orthotic industry. Thetiming could not have been better.Americans were beginning to catchthe fitness bug. The running craze ofthe 1970s and other fitness fadsstarted leaving many people withlower extremity injuries and becausepodiatry had just recently acquiredthese important new skill sets, pa-tients flocked to their offices.

Armed with an organized, scien-tific approach to the assessment and

to fade as scientific conferencesbegan to diminish the biomechani-cal content and increase the frequen-cy of the ever-captivating surgicalprograms. For awhile there was aneffective balance between these twoworlds. The surgical thought leadersof the time recognized the intricateconnection between the biomechan-ical function of feet and the surgicaltechniques that were being devel-oped to change them. In time,biomechanics became the symposiastep children. The profession was be-coming enthralled with a less conser-vative, but more exciting approachto treatment. The new skills beingtaught were beginning to replace thefoundations of knowledge that pre-ceded them.

This was also the time when pro-fessional fees began to be reduced bythird party payers. Starting in Cali-fornia in the mid 1980s and spread-ing eastward over the ensuingdecades, podiatrists were findingthemselves working harder andbeing paid less. Reduced fees didn’tdiscriminate. Whether you were asuper star surgeon or a biomechani-cal whiz, you were beginning to getpaid less for the services you provid-ed. There were several unintendedconsequences of this economic shiftwhich has had a profound effect onthe orthotics industry and led to the

current explosionof lower cost, retailalternatives.

A DownwardSpiral

One of thefirst casualties ofthe changing eco-nomics was inno-vation from the or-thotic manufactur-ers. There has al-ways been an un-usually large gap

between the profit margin of the lab-oratories and the profit margins ofthe podiatrists for foot orthotics. Typ-ically, a well-run full-service laborato-ry could generate net profits of be-tween 10%-20%. So, on each pair oforthotics the labs would generate be-tween $8-$20 of profit. Podiatrists onthe other hand were generating ap-proximately $200-$300 profit. As re-duced fees began to erode overall

The Big One...

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Undeniably,

the fastest growing

area where

Americans are

getting their foot

devices is at retail.

ated. The understanding and atten-tion to the underlying biomechani-cal principals was less and less evi-dent from the practices, and themanufacturers were being asked todo more and more with less revenue.Something had to give. Innovationwas only the first casualty. Labs, stillunable to raiseprices, needed tomake otherchanges in orderto absorb theirever- increasingcosts. To be fair,many labs did de-velop more effi-cient manufactur-ing methods, justas many podia-trists resisted prac-tice shortcuts. Butother labs beganto cut other cor-ners as well. TheRoot methods for preparing castsand balancing deformities dimin-ished. The level of professional sup-port from the laboratories was lost orreduced. Some labs even stoppedproducing custom products. Instead,libraries of casts or orthotic shellswere developed and simply matchedto the casts sent in for custom-madeappliances. Again, all of thesechanges had the effect of reducingthe need for specialized production

and the clinicalexpertise that wasinherent duringthe early years. Ev-eryone’s bar waslowered.

Other Providersand SavvyRetailers

While that washappening in podi-atry, there wereother healthcarepractitioners whowere feasting onthe newly created

opportunities. Physical therapists, pe-dorthists, orthotists and chiropractorswere only too willing to make the in-tellectual investment necessary to getinvolved with foot orthotics. Manypatients, who only a decade earlierwould have found their way to a po-diatry practice, were now able to ob-tain their foot orthotics elsewhere. It

practice profitability, podiatrists werebeginning to demand price conces-sions from all of their suppliers, in-cluding their orthotic companies.With virtually no entry barriers,small new labs began popping up allover the place willing to comply withthe low price demands of their cus-tomers. This trend has not yet ended.There are many labs which have notraised their fees in ten years. The larg-er labs, who had been responsible forall of the innovations during the1970s and 1980s, either scaled backor stopped altogether their productdevelopment investments. The mar-kets seemed less and less willing topay for these innovations, and thelabs needed to remain economicallyviable. By not continually innovat-ing, the laboratory world became eas-ier and easier to copy and the special-ized needs of the prescribing podia-trists became less and less necessary.Essentially, the seeds of commoditiz-ing orthotics were beginning to besewn.

Podiatrists, too, were beginningto make behavioral changes in theirprescribing habits. As the pressuresof practice increased, DPMs begantaking some shortcuts. Full biome-chanical assessments were becomingless common. Once an integral partof a standard orthotic protocol, theseexams were nowbecoming the ex-ception. Castingtechniques beganshifting awayfrom neutral posi-tion plaster slippercasts and labsstarted receivingcrush box ordersevery day. Becausebiomechanical ex-aminations be-came less promi-nent, the special-ized prescriptionsalso became lessfrequent. Poorly taken casts with in-complete or inadequate prescriptionsbegan to fill the capacity of laborato-ries around the country. Obviously,this didn’t reflect every practice, butthe number of “plain vanilla” or-thotic orders were increasing at analarming rate.

A downward spiral was being cre-

is now estimated that podiatry dis-penses less than 50% of the health-care provider orthotic prescriptionvolume.

The only thing that never dimin-ished was the need for foot orthotics.If anything, the demand was goingin the opposite direction. As our cul-

ture remainedcommitted to fit-ness and as thebaby boomersbegan to age, thenumber of lowerextremity prob-lems has contin-ued to grow. So,with the qualityand complexity oforthotics in de-cline, and theneed for them in-creasing, it wasonly a matter oftime before pa-

tients were going to be transformedinto consumers. The early efforts toprovide retail solutions were mostlythe work of podiatrists themselves.There were a number of en-trepreneurial DPMs who connectedwith their laboratory to create mailorder orthotic businesses. With theadvent of crush foam boxes, thesebusinesses were able to create a na-tionwide mail order business usingtraditional advertising. Laboratoriestoo were seduced into getting a pieceof what was thought to be a very lu-crative market. Remember, labs wereonly generating about a $15 profitfor a pair of orthotics. Presenting a$200 product to a patient and cut-ting out the podiatric middlemanwas a financial home run.

As time and technology evolved,there were more and more ways toconvey the benefits of foot orthoticsto people suffering from foot pain.Infomercials, online businesses andeventually brick and mortar retailersbegan to dot the foot care land-scape. If you scratch deep enough,there was still a podiatrist or labora-tory involved. The opportunity thatretail foot care represented wasstarting to get the attention of largecompanies as well. The latest itera-tions of the retail efforts leveragesthe 2D and 3D scanning technolo-gies that are available today.

So whether it’s one of thousands

The Big One...

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The podiatrist has

evolved to the very

narrow end of the

funnel for people

seeking pain relief

from functional

orthotics.

The fact remains that podiatristsare the best-trained and most highlyskilled professionals to deal with footproblems. The thorough understand-ing of foot mechanics, foot deformi-ties, compensatory actions of variousjoints in feet and orthotic modifica-tions should help to reestablish com-petitive advantages for podiatrists.Many DPMs low-ered their orthoticstandards partlybecause of the in-ability to managethe compliance oftheir patients.Pressure over shoestyles and feescaused many prac-titioners to offerlower functioning(quality) devicesor lower cost alter-natives, ratherthan what couldhave been the best solution. Thesepractice compromises should beminimized. Your measure of successshould be more than a lack of com-plaints by patients. You should al-ways ask yourself if you have doneall that is possible to treat a chroniccondition. The devices that your pa-tients can acquire at retail may pro-vide some help. But the more impor-tant question for a physician to askis whether they are actually gettingbetter, or simply getting worse moreslowly. If you can get them better,then no other consideration shouldtrump that.

Preserving the value of the podia-try-prescribed functional foot orthot-ic requires:

• Maintaining or reestablishinghigh standards for biomechanicalevaluations.

• Maintaining or reestablishinghigher technical standards for properprescriptions.

• Investing in proper researchthat supports the efficacy and safetyprofile of foot orthotics.

• Supporting companies that in-vest in product innovation and com-plying with generally accepted man-ufacturing standards.

• Gaining greater control overpatient compliance.

• Investing in educational effortsgeared to enhance the understand-ing of biomechanics.

• Maintaining high standards of

of retail franchises (Good Feet,Neovita, Foot EFX, Ideal Feet, FootSolutions, etc.) or the New BalanceProcare dealers or Costco or more re-cently Walmart, Americans have aplethora of lower cost convenientplaces to get their “foot orthotics”.Are they getting the same productand service that they would at theoffice of a competent podiatrist? Ofcourse not. Does the public under-stand this? Probably not. Does thismake it more difficult for podiatriststo do a good job with orthotics? Ab-solutely! Patients are coming into of-fices every day with failed orthoticsand podiatrists have to walk thetricky line between telling them thatthey may have been misled (orworse, ripped off) and the fact thatthey still do need a properly pre-scribed and crafted functional footorthotic. It is hard to know if all ofthese retail opportunities would haveexisted if the early standards hadbeen maintained, given the currentdrive to reduce costs. One thing iscertain, Podiatry, in concert withtheir suppliers, made it relativelyeasy for the shift from professionalto retail to take place.

Tactics and StrategiesThe genie is out of the bottle,

and most likely will never be com-pletely put back in. There are, how-ever, tactics and strategies that canbe instituted that will help maintainthe relevance and value of a podia-try-dispensed orthotic. While muchof the same pressures exist in Cana-da, the healthcare system and insur-ance industry have maintainedstrong reimbursement for foot or-thotics. This is turn has cushionedthe health care providers from retail-ers because the foot suffering pa-tients have a fundamental belief thatthey will be best served by trainedprofessionals. For some insuranceplans prescriptions are required forfoot orthotics and there are specificspecialties identified as proper toprovide those prescriptions. Further-more, some insurers have identifiedcertain manufacturing standards inorder to utilize the term custom-made functional foot orthotics.These approaches have had the ef-fect of minimizing the impact of en-terprising retailers.

biomechanics in the podiatryschools and residency programs.

The Laboratory RelationshipThe laboratory relationship is also

a key element in holding onto theposition of preeminence for dispens-ing foot orthotics. Reward producersfor innovation (yes, that means pay-

ing a higher pricefor a better prod-uct). Resist thetemptation to fleeor negotiate whenthey need to raisetheir prices tocover increasedcosts. The distribu-tion of the profitmargin is stillhighly in favor ofthe practitioner.This will avoid fur-ther corner cuttingand diminution of

quality in professional foot orthotics.Seek suppliers who still conform tothe evidenced-based approach to or-thotics and who continue to incorpo-rate good manufacturing practices.Laboratories that help fund researchefforts and provide professional con-sultative services should also be re-warded with your patronage. It’s ev-eryone’s job to ensure that the bar isnot lowered any further.

Become familiar with this scien-tific work and convey this to yourpatients. Learn, or re-learn about theorthopedic management techniques.Don’t duck when patients ask you toexplain the differences between the“custom fit” products that they areexposed to and the “custom-made”product that you want to prescribeto them, made from their cast andbased upon sound biomechanicalprincipals. Your fundamental beliefin their therapeutic value will beconveyed to your patients. �

The Big One...

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In the second half

of the 80’s scientific

conferences began

to diminish their

biomechanical

content.

M r . K r a u s i sCEO of LangerBiomechanicsGroup and hasheld executivemanagementpositions in thehealthcare in-dustry for over25 years. He isco-author of theregular PM column From the Files ofSOS.