Prescription Custom Foot Orthoses (PCFOs)

Professional Guidelines Regarding Prescription Custom Foot Orthoses (PCFOs)

Preamble

Prescription custom foot orthoses (PCFOs) are an integral part of patient care for podiatrists in the management of pedal pathologies and are used to improve gait and alleviate pain and discomfort from abnormal foot function or structure.

These guidelines outline expectations of podiatrists with respect to prescribing, constructing, and dispensing PCFOs. The prescription of PCFOs is dependent upon many variables, including the patient’s medical history, footwear, activities, and work environment.

Guidelines

As a result of the personalized treatment plan and this process, deviations may be unavoidable in certain circumstances. PCFOs can be functional devices, accommodative devices, or a combination of the two. In these situations:

• the patient’s chart should clearly document the revised treatment process and the justification for any deviations from this professional guideline; and,
• when charging for PCFOs, the podiatrist should set fees that are fair and reasonable with the service provided and communicate the fee with patients in advance.

This professional guideline does not apply to prefabricated over-the-counter orthotics/inserts. Although these can be helpful on their own or can be modified to accommodate the patient’s foot or condition when appropriate, they must not be conveyed to the public as a PCFO. For more information on selling over-the-counter orthotics, please see the College’s Professional Standards Regarding Sale of Products and Services to Patients by Podiatrists.

Prescribing of PCFOs

Functional Device  

Functional PCFOs are prescribed to control and/or improve the function of the foot to a specific degree as determined by a thorough biomechanical evaluation to alleviate pedal and lower extremity musculoskeletal symptomatology. They can prevent or slow down the development of abnormal forces and subsequent deformities by mechanical control, which may be due to structural weaknesses, deformities, or overuse symptoms. A prescription of a functional orthotic should include:  

• a thorough biomechanical examination with appropriate measurements taken and recorded;  
• a stance and gait analysis; and,  
• Plaster of Paris casts, STS slipper casts or equivalent, or 3D volumetric images of the feet (e.g. 3D digital image scanning). It is important to remember that the quality and efficacy of the PCFO is dependent upon the accuracy and precision of the negative cast or 3D volumetric image of the feet.  

Accommodative Device  

An accommodative device is prescribed for patients for whom a functional device is not appropriate. Objectives for accommodative orthotics are to provide a measure of control to the function of the foot, to alleviate pedal and lower extremity musculoskeletal symptomatology, to prevent the worsening of pedal deformities by mechanical control, and deflect pressure from ulcers, tissue pathologies, and areas of excessive pressure, which permits forces to be more evenly distributed to the foot and enhance cushioning of the foot. Indications for accommodative PCFOs may include structural weaknesses or deformities, pain, and a high-risk foot with a potential for soft tissue breakdown. Prescription of an accommodative PCFO should include:  

• a thorough biomechanical examination with appropriate measurements taken and recorded;  
• a stance and gait analysis (where appropriate); and,  
• Plaster of Paris casts, STS slipper casts or equivalent, or 3D volumetric image of the feet. 

The assessments outlined above for the prescription of both functional and accommodative devices are to be done by the podiatrist and not delegated.

Constructing PCFOs 

PCFOs must be constructed from the prescription and fabricated from appropriate materials in consideration of the patient’s diagnosis, footwear, and activities.  

Dispensing PCFOs  

1. PCFOs should be dispensed by the podiatrist to ensure that the fit of the device meets the prescription and the contours of the patient’s foot.  
2. Podiatrists should provide the following to the patient in a manner that is clearly understood:  

* If no follow-up appointment is scheduled or kept, reasoning must be clearly articulated in the patient chart.  

Resources

College of Physicians and Surgeons of Nova Scotia: 

• Professional Standards Regarding Sale of Products and Services to Patients by Podiatrists 
• Professional Standards Regarding Conflict of Interest for Podiatrists 
• Professional Standards Regarding Billing for Podiatrists 

Acknowledgements

The College of Physicians and Surgeons of Nova Scotia gratefully acknowledges the College of Physicians and Surgeons of British Columbia for permitting sections of their Professional Guideline on Custom Orthotics to be adapted in the preparation of this document, and to the Nova Scotia Podiatry Association for their adaptation of such.

Document History

Approved by the Council of College of Physicians and Surgeons of Nova Scotia: March 21, 2025