Ep.30 Orthoses in Clinical Practice with Gus McSweyn

Unlock the potential of orthoses in managing foot and lower limb conditions with the expert insights of Gus McSweyn. In a captivating exchange, Gus McSweyn unveils his philosophy on utilising orthoses to balance tissue capacity with demands, offering a fresh perspective on customising orthotic selection. He emphasises a strategy focused on reducing the load on ailing tissues, while simultaneously building their strength. This episode is a treasure trove of practical knowledge for healthcare professionals and enthusiasts alike, seeking to refine their application of orthotic therapy in clinical practice.

This discussion is more than just an exploration—it's a deep dive into the nuanced art of orthotic therapy, underscored by the importance of a personalized, conservative approach to treatment. Join us for an episode that seamlessly bridges the gap between theory and practice, providing invaluable insights for those looking to enhance patient care through orthotic solutions.

@simplythebestpodiatry

www.movepod.com.au

@movepod

@gusmcsweyn

www.thegenie.au

@jasonagosta

Transcript

Speaker 1: 0:09

Welcome back to Simply the Best Penitree, where we want to pass on simple tips to enhance your best practice. I am Jason Augusta and this episode is part two of our orthoses in clinical practice series. I spoke with Gus McSwain and Sophie Fit about their approaches to using orthoses in clinical practice. Both Gus and Sophie have both contributed to this show in the past. Gus has been on the show previously discussing running, footwear and injuries, which was episode 15, and he is from Moved Pod Pediatry in Torquay in Geelong here in Victoria. The whole deal with this is being everybody's podcast show. I just seem to be the person hosting it.

Speaker 2: 1:01

But it is a show for everybody.

Speaker 1: 1:03

It is a show of the people. So the idea of this is to start this series on orthoses and just get a really broad idea of what people think and what they are doing. There is no right or wrong. It is all about philosophy and your ideal ways of working in your practice. There is not going to be a focus on evidence that we will go through a little bit in one of the episodes but that is definitely not the focus. This is very much practice and skills and ideology and things like that. Then we are going to move on to focusing on details like preformed orthoses versus the casted or scammed or whatever you want to call them, custom orthoses. We just really want to bust this open, get people talking, just getting people's opinions and get people talking about it, because we never hear pediatrics talk about orthoses.

Speaker 2: 2:00

No, it definitely should be.

Speaker 1: 2:02

I had a quick chat to Matt Molliker, which you may have heard, and by the time this goes up you would have heard it. Just get people to open up and tell us what you are doing and what you think and pass on lots of messages and ideas. That is what it is about. I love it.

Speaker 2: 2:22

It is good conversation.

Speaker 1: 2:24

The first question is where do you stand with the use of orthoses in your practice, like? Where is your approach or philosophies?

Speaker 2: 2:34

My perspective on approach is I am very much the hands-on, soft tissue based aspect of injury management, as you probably heard in the running footwear base that we did. It is around what that tissue capacity is versus the demands going through it. As a pediatrist, we are very lucky that we have the skill set where you can use shoes, orthoses, taping to be able to modify rates, range of movement, all that kind of stuff and loading patterns. Orthotics is just another tool that I use in that toolkit to be able to help with that. A really big philosophy way that I would probably look at it is around if there is symptomatic tissue, if there is a structure that is being overloaded, that is uncomfortable, causing pain, causing inability to activity, then it is around figuring out why you can have structural aspects that lead to that tissue being loaded more. You can have activity based. Then it is around figuring out where their threshold or capacity sits, where that tissue tolerance is.

Speaker 2: 3:37

How I look at an orthotic is in one or two ways. One it is to help bridge the gap between where that tissue's capacity is versus the demands that go through it, utilizing the characteristics of that orthosis to reduce load on that tissue or reduce load on that structure. Obviously we cannot make load disappear. You just redistribute it elsewhere. It is reducing load on that symptomatic tissue so that then you can bridge that gap while then putting hand in hand a little bit of strength and conditioning that kind of stuff to then increase that capacity while using that orthotic. Then it is also around from a structural perspective. If there is structural characteristics of that foot and lower limb and how it moves, helping to address some of those characteristics that are leading to that tissue then becoming overloaded or becoming sore or creating deformity.

Speaker 1: 4:27

Yeah, okay. So you're speaking to me about, say, tib post pain or long flexor tendon pain, and what you're doing is trying to offload or redistribute the stress and then focus on the soft tissue aspect of things like strengthening.

Speaker 2: 4:46

Yeah, so de-load the tissue and then help to bridge that deficit through strength work.

Speaker 1: 4:53

I think that's a good point, though, isn't it? So what you're really saying? You're very aware and obviously doing this in practice that the orthosis are only one part of the whole treatment plan yes, which you're obviously passing on very clearly to your patient, but the offloading and then focusing on all the other aspects of how we're going to get this person right yes, exactly, it's well done so with the part about orthosis is that becomes a crucial part in offloading. And although we can reduce say, if we talk about runners, for instance, we might be able to reduce 50% of training load, or maybe even go 20% or 30% as part of that plan. But so what would you be using in that scenario, though, as far as devices, in an attempt to sort of offload the stress to a part, yeah.

Speaker 2: 5:47

And again it then comes down to what the actual tissue is that needs to be deloaded, because different characteristics will deload different aspects of that foot and lower limb. So if you go with your classic like Tib post presentation, traditionally you'll need a little bit of rear foot and midfoot device change through that. So adding some of that rear foot control is really important in that, whereas if you've got a four foot deformity like a HAV, you may only need more of that distal contour to be able to help alleviate that load and stress. So again, it's one of those things where there's certain characteristics that will work really well in certain presentations. So it's kind of not a one shoe, one stop fits all kind of thing. So that's where it comes down to each presentation that sits in front of you.

Speaker 1: 6:39

And that's our judgment, isn't it? Yeah? And our experience of what we think might be the best way to go about that, or what devices to use or what sort of where you want the support to be. So if we talk about devices specifically, what are you using?

Speaker 2: 6:54

So, device wise, I use a range. Obviously I use a customized orthotic. My preference for them at the moment is the team at Footwork and so that's just a 3D nylon printed custom orthotic in that rigid shell. Very rarely would I use like a customized EVA device. Typically it's that 3D device. Then, from a prefab perspective, using some form thottics, using just some of the over the counter devices of that four degree kind of mid device, depending on presentation and also having to play around with a little nylon printed device at the moment.

Speaker 1: 7:35

Yeah, we'll talk about that.

Speaker 2: 7:39

Yeah. So they're probably the go-tos and again, my decision making around what I use out of those will really come down to the presentation, how long it's been there, for what are the characteristics leading to it and also how big is that gap that you've got a bridge. So Of support, is that what you meant? Yeah, of support and like. So if we talk about that tissue capacity again, if a certain structure, if imagine that tissue is 70% lower than where it needs to be and it's going to take you 12 to 16 weeks to bridge that gap in strength, base loading, then obviously you're going to need higher degrees of correction or more specific aspects of deloading that you might not be able to get out of a prefabricated device. So all those kind of things, as well as cost and that kind of stuff and client expectation come into that too.

Speaker 1: 8:31

So just on that point, though, like you might need something higher to try and offload that part and get this person better, are you then pulling back on the levels of support that that person may need once they settle down? Yeah, so I would stay with that. You know, pretty a printed device Device.

Speaker 2: 8:51

Yeah, and that's a conversation that I'll have with individuals where, ideally, if there's no structural characteristic that's led, so, if there's no like long-term acute osteoarthritic change, if there's no acquired deformity through that, if it is purely just bridging that gap, then yes, it's a device that will use to deload, get them stronger, get them adapted and then get them out of it, whereas for some individuals it's around. Look, this is going to be something that you're going to need longer term, because it doesn't matter how much we strengthen that tissue, but there's going to be so much demand going through that that unfortunately there needs to be that level of deloading.

Speaker 1: 9:28

Yeah, that's what we see with the degenerative changes, isn't it? Soft tissue and joint, you just got to hang in there. And sometimes those older patients they're not going anywhere except being well supported. Yeah.

Speaker 2: 9:39

But the tricky aspect from that is to build capacity takes a fair bit of work, yeah, and then also got to have the buy-in to maintain that capacity as well. So it's all those kind of little considerations in the journey too.

Speaker 1: 9:52

So, going back to what you said about using a variation of preforms, are there some really good aspects and then problems With the devices that you use. Yeah, so I think you have to get your hands on and fix up and modify and yeah.

Speaker 2: 10:07

Do the stuff that we do as you know, with, like your preforms, a lot of them are cut to a certain yeah, a certain, and a lot of them are that kind of mid device for degree kind of set up when you get them and so some presentations that works really well.

Speaker 2: 10:21

But, as you know, every foot that pretty much walks through the door We'll have a different arch profile, will have different rates of movement, different loading characteristics, so you can't really just put that under every foot. You see, for some presentations where they just need some of that Short-term arch, contour, structural support, that kind of stuff, that's where I use them quite well. So, like it might be that you have to reduce a little bit of that degree of correction or soften the device it's that EVA device or make a little bit more contour, distally to make it a bit more comfortable for that individual, yeah, but if it's something specifically where I've got to really bridge that gap that's where I look more at that customized device or if it is that deformity or ongoing chronic change, then yeah, okay, the way that I look at it is it's amazing tool that we have a skill set to be able to use and, if used correctly, can transform someone. How would it be in a state of being able to do activity, all that kind of stuff.

Speaker 1: 11:21

Yeah, yeah, yeah.

Speaker 2: 11:22

It's that education piece where it's and I think physio is really appreciate and understand. When you break it down and say, look, the tip post is so far off being able to tolerate the load that goes through it and then you redistribute load away from that, that can only be a positive aspect. Then enables that person to be able to walk to the coffee shop or whatever.

Speaker 1: 11:39

The hell it is.

Speaker 2: 11:40

I think physios as well potentially might be like well, it sucks if Someone walks through your door and you can dispense an orthotic forum which, from like a revenue and cash perspective, makes it Obviously a turnover, whereas for them there are their modalities for that probably aren't as great either.

Speaker 1: 11:55

So you know what you know. Comment was back to the five. Yeah, I think you guys are dispensary services In that you have all the preform stuff to use and you just hand them out. They just chuck them out. They're actually knowing what the hell's going on, yeah, and they said, yeah, you're probably right. Yeah, that's five really good people, very, you know, diplomatic and very reasonable. But it was good conversation.

Speaker 2: 12:20

Briefly, I've talked to clinicians where they'll go. The only device I prescribe is a rear foot device. Mmm and they'll be like I don't put any distal contour under, like so I can someone to be walking in front of you with a sesamoid based injury. And I'll be like, yeah, I just put a 14 degree rear foot device. Yeah, yeah, yeah, okay. No wonder people out there are like what's going on in the world of put on yeah yeah, exactly, man, I've got to ask you this.

Speaker 1: 12:44

Your six years out of college? Yep, you've got a maturity beyond your years. You speak unbelievably well and confidently about what you do. Yep, you're clearly Intelligent about what you do. Where does this come from?

Speaker 2: 13:03

Yeah, it's good question. I just talk to a lot of individuals. So I was lucky enough in the early years like obviously trying to find people like you, find different podiatrist out there that have done it for a while and try and get some insights from them. And then it's just around like trying to appreciate what actually the key characteristics of what we do and try and get the best you can at it.

Speaker 2: 13:29

So, like from a podiatrist perspective in a global sense, a lot of people are like in an elite, sporting sense, like I said, the general care or it's orthosis or shoes. So it's like, well, if you're going to be a podiatrist, it's like that you get bloody good at doing those things. And then to get bloody good at it, the way that you give yourself confidence without potentially having 20 years of experience is just learn the hell out of it, so you learn as much as you can and then, once you've got that learning base, you can then apply it. And then it kind of becomes that fundamental thing where it's like, well, I've learned it, a lot of experienced people that have done it do it this way. The evidence or whatever literature is out there to a degree tells you to do it that way, and then you apply it, and then that's yeah, beautiful, so well done.

Speaker 1: 14:11

That's the idea, because Well, the idea, I think, is working pretty good for you. That's great, mate. Thank you. It's so clear. In a few minutes you've told me where your philosophy is and the focus on tissue stress and what you're doing with preforms to a certain point, and then you're moving on to the 3D printed devices for greater level of support. Perfect, gus. And I have to say, enjoy your summer preseason down at Esadam Footy Club Always good. Well done, mate. Thanks for joining me. I really appreciate your input into this series and I hope it makes sense for everybody. And Gus, again, once again, thanks for coming on, but also I hope that you can listen in and get a feel for what everyone else is doing as well.

Speaker 2: 14:57

I love it. It's a great discussion point and it's definitely how the profession continues to evolve. Is you get people talking about this kind of stuff, which helps not only us as individuals grow, but probably helps the general community get a bit more of an idea around what we actually do and the considerations it takes?

Speaker 1: 15:14

Yeah, exactly, mate. Thanks a million and we're going to speak soon anyway, but thanks for joining me again and contributing to this essential series and we'll speak soon. Pleasure. Thanks, jason. Thanks, man. Moving on, I spoke to Sophie Fit, who is from Fitzroy Padatri. Sove has contributed to this show previously with the hugely successful episode 18 on metatarsal stress fractures. Here I spoke with Sophie regarding her orthosis use in clinical practice, thinking to five or six podiatrists getting their opinions on just philosophies, your ideology of the use of orthosis in practice, and the second part is what are you actually using? So it's quite brief, but just getting an overview from lots of different people. Basically, there's no right or wrong, it's really just learning what people are doing. So others can learn from these short discussions but also realize that there is a big variation in what we do with things and it is very much practice related, totally. So the first question to you, sove, and thanks for coming back on your episodes have gone through the roof.

Speaker 1: 16:35

So I really appreciate your contribution to simply the test. Podiatry Metatarsal fractures has gone through the roof Sove.

Speaker 3: 16:42

Yeah, I saw it in right back to you. When you said that nice comment there, sove, I meant to say that you do make it very easy. Maybe they question how they're diagnosing them and they just thought that that's something they want to learn more about. I don't know. Yeah, well, I mean that's the aim of the show For people to communicate with differentials.

Speaker 1: 16:58

I don't know, yeah, yeah, yeah. But look, it's a common thing and you know, people just want clarification and really I suppose if you gain some understanding that's great, but just knowing where you stand is a good thing.

Speaker 1: 17:10

You know, it's a topical point, like as is this with orthosis and podiatrists. So, to begin with, the first thing is so, and obviously this has changed for all of us over time. But what's your sort of sort of approach to using orthosis clinically, like when do you decide to use something and you know what sort of the criteria you might use in using orthosis for solving problems and treating people clinically?

Speaker 3: 17:44

Very rarely use an orthotic or prescribe an orthotic without testing firstly how I think a patient will receive the device using something else, and so, for example, I wouldn't prescribe an orthotic without first using tape, for example, so altering the posture of the foot using tape, to then see how it might respond if an orthotic was included down the track. What I'm saying is I don't generally just go straight to orthosis. There's usually a few steps before the prescription occurs, and where I've come to or I guess how do I best say this is the pathologies or presentations that I find I'm using orthoses more is when temporary modalities for forefoot presentations so felts and foams and various other things that I may have tried with a temporary sort of purpose have been successful, I may move forward with an orthotic to then create a more permanent solution to what that strategy has created for the patient. So I really like orthoses with forefoot offloading. I really like, in the use of, say, any sort of first MTP presentation, be it sesamoids, helix, limitus rigidus, even some HIV stuff when I can get in there and prescribe something with some really good foams that are, you know, manufactured in a much cleaner and better way than I can create in the clinic.

Speaker 3: 19:29

I find the six to 12 months, 12 to 18 months and more years that of relief that a patient can get from that strategy is really, really helpful. Which is probably going to sound a little bit different to what people would naturally think of orthotics I mean, we always think of, we often think of midfoot, rear foot stuff. So I thought I'd come in here straight up and just say that the forefoot stuff is really is how I really like to use orthoses. Creating metatarsal domes you know, through the laboratory that we work with, being able to play around with different metatarsal dome fitness, position, density, all that sort of stuff is just sorry about the background noise. That's just extra, a greater offering for a patient than what we've got in the clinic and that's where I think customs can help. But generally speaking, like when I'm working full time, I don't think I prescribe more than one pair of custom made foot orthoses per week.

Speaker 1: 20:38

Sure.

Speaker 3: 20:39

Like I think it would be. I honestly don't think I. Oh, at some weeks I wouldn't even do that. So customs aren't something I'm reaching for very frequently at all. I don't use the basis like a patient walks in with, you know, a pair that they've had for 15 years. They're looking very overworn, disheveled. That is not a reason for me to prescribe a new pair. That person's just another person. I'm starting from scratch with.

Speaker 1: 21:07

Yeah sure.

Speaker 3: 21:08

But if they've responded well to taping techniques perhaps felt or foam in their shoes and I am just looking for a more permanent solution, that is probably the number one reason or deciding factor for me to proceed with something, be it a generic prefabricated device or something customized, sure.

Speaker 1: 21:31

So it's very much a conservative approach initially.

Speaker 3: 21:34

That's what you're saying Very conservative and using them fairly sparingly, if I'm honest.

Speaker 1: 21:44

Okay, so are you using lots of preforms?

Speaker 3: 21:50

Yeah, so in our clinic we use the form thottics as a generic prefabricated device, and in the presentations of heel pain or any form of plantafascia discomfort I would probably prescribe a generic prefabricated orthotic, perhaps one in three or one in four plantafascia presentations.

Speaker 1: 22:15

Yeah, okay.

Speaker 3: 22:16

And that is based on the research of my colleague, glenn Whitaker, who compared the long-term effects now comes of a steroid, corticosteroid injection with a generic orthotic and did use form thottics and that had nothing to do with foot posture but was based purely on plantafascias. And I, having trialed tape and I do use your taping technique in shifting the foot into greater supination to offload that pronation and the plantafascias, if that has been successful and in consideration of other factors, especially footwear, lifestyle activities, body composition, you know that's where that one in three patients with a plan of heel pain presentation will almost always be offered and probably walk away with a prefab from me. And that's always with the discussion that this is a six to 12 month strategy. It's certainly not a long-term, long, long-term kind of thing, but it's absolutely with the next six to 12 months in mind and I find those patients go really really well.

Speaker 1: 23:26

Okay, so the focus is being conservative and using preforms predominantly. That's what you're saying. Can I just pick up on that point you mentioned about the injection and the use of the foam inserts? Yes, so what was the outcome of all that.

Speaker 3: 23:42

The outcome was that a generic prefabricated orthotic and he used the form-thotic brand was more successful in providing long-term asymptomatic outcome for plan of heel pain than a corticosteroid injection.

Speaker 1: 23:59

Right, so just having mild support was enough.

Speaker 3: 24:02

Correct yeah.

Speaker 1: 24:04

Yeah, okay, okay. So as far as when you do use orthoses, as far as preforms or you said, once a week you might make a custom, or is what are you actually using?

Speaker 3: 24:17

You mean, when I do a custom, what am I using?

Speaker 1: 24:19

What are you in preforms? You said you're using the foam styled EVA devices.

Speaker 2: 24:25

Yep. And then what about if?

Speaker 1: 24:27

you move on to the customs. What are you actually doing or what are you using? Are you scanning or still taking plaster?

Speaker 3: 24:34

So the material I most frequently would choose is a polycarbon or a carbon composite material and I in almost all cases will do like a polycarbon shell with a full length top cover. Very, very rare that I prescribe a three-quarter polycarbon, so the sort of shell only device. But if that is the patient's overwhelming preference then of course we work with that. The reason I like a polycarbon shell with a full length top cover is it's the top cover more so that I'm utilising to add in the bits and bobs that I'm trying to, that I'm using to offload whatever I'm trying to offload.

Speaker 3: 25:21

Yeah, a forefoot padding, all that stuff, and it's the very start of my spiel about utilising carbon foot orthosis sorry, custom foot orthosis for forefoot pathology. So I like the polycarbon or the carbon composite shell. I just think it's a really nice bit of flex in it. It's not heavy like the polypropylene but it's very durable. Obviously, you know, with the price point of CFOs we are looking at durability and often those forefoot pathologies, for example, are of the chronic, long-term nature. So I really am looking at a long-term device and I really like the lightness, I like the advancement in that polycarbon material. It's not the only thing I use, but I do do a little bit of the dual density foams. I don't mind them in the right setting, but I love a polycarbon shell with a full length top cover. I always do a performance top cover, sort of the Canberral base, the EVAs, with some pour on. You know like I'm talking. I'm trying to create comfort, cushioning support. I want the patient to step on it and really feel ultimately great comfort.

Speaker 1: 26:31

Sure Okay.

Speaker 3: 26:32

That's what they need to feel, but then I know what's happening to the foot. To offload, alleviate, address, whatever it is that requires.

Speaker 1: 26:44

Sure.

Speaker 3: 26:44

Yeah.

Speaker 1: 26:46

So can you modify those devices yourself afterwards.

Speaker 3: 26:50

Yeah, I very rarely need to. But yeah, absolutely. So any grinding can occur, things can be pulled off, absolutely, things can be added, etc. But I tend to make the prescription very specific and I know exactly what I want the orthotic to look like and I you know we're working with orthotech at the moment and I think they're great. I often will call them before you know, between sending the scans off and expecting the device back, and get really specific about I want, about what I want, and for those reasons I tend not to need to adjust them. But yeah, you can, absolutely.

Speaker 1: 27:25

Sure, okay, all right, that's great. So thanks so much for your input. I really appreciate your time once again and a very concise discussion.

Speaker 3: 27:36

Thanks for letting me join in, jason, otherwise, All right, thanks, so see soon See ya.

Speaker 1: 27:41

Okay, bye. Thanks for listening and that's the second part of our orthoses in clinical practice series. Please get in touch if you want to chat and come on the show. Genie orthoses are sponsoring these orthoses in clinical practice episodes. More details of genie orthoses can be found at thegenie the genie, which will be on the show notes. You can also follow and support this show through the notes. Thanks for listening and stay tuned for more orthoses in clinical practice episodes. See you soon.