C.Ped cheat sheet

Palpate dorsalis pedis and posterior tibial pulses bilaterally; absent pulses, dependent rubor, or hair loss warrant vascular evaluation before any device is fabricated.

Ankle-brachial index below 0.90 indicates peripheral arterial disease; an index above 1.30 indicates non-compressible calcified vessels, common in long-standing diabetes.

10-g Semmes-Weinstein monofilament: inability to perceive the force at one or more plantar test sites equals loss of protective sensation; pair with 128-Hz tuning fork vibration testing.

Subtalar joint neutral is the position of talonavicular congruency with no medial or lateral bulging; all forefoot-to-rearfoot measurements are taken from this reference.

Resting calcaneal stance position of 2 to 6 degrees everted is typical; forefoot varus means the forefoot is inverted relative to a line perpendicular to the rearfoot in subtalar neutral.

Ankle dorsiflexion with the knee extended of less than 10 degrees suggests gastrocnemius or soleus tightness; the Silfverskiold test separates gastrocnemius from soleus limitation.

Three gait rockers drive the ground reaction force: heel rocker at initial contact, ankle rocker in midstance, forefoot rocker at push-off; pain localizes the rocker to be offloaded.

Wagner ulcer classification runs 0 to 5: 0 intact skin with deformity, 1 superficial ulcer, 2 deep to tendon or bone, 3 abscess or osteomyelitis, 4 partial gangrene, 5 whole-foot gangrene.

Leg length is screened by tape measure from anterior superior iliac spine to medial malleolus; a difference under 2 cm is usually managed with an internal heel lift.

Treatment goals are ranked in this order: redistribute pressure, accommodate fixed deformity, add cushioning, correct flexible deformity only, and control unwanted motion.

Medial compartment knee osteoarthritis is offloaded with a lateral wedge insole that reduces the external knee adduction moment; avoid this when lateral compartment disease predominates.

Neuropathic plantar ulcer: total contact casting is the gold standard, contraindicated with active infection, osteomyelitis, or severe ischemia, in which case a CROW or removable walker is used.

Foot drop prescription: a hinged AFO blocks plantarflexion while permitting stance-phase dorsiflexion; a solid AFO is chosen when mediolateral ankle stability is also required.

Diabetes: prescribe extra-depth footwear with removable insoles providing at least 3/8 inch of extra depth, paired with a multi-density insert and no seams over bony prominences.

Metatarsalgia or first-ray amputation: a stiff forefoot with a rocker-bottom sole reduces peak pressure at the metatarsal heads during terminal stance.

Heel lifts greater than 2 cm are placed on the shoe or split between shoe and orthosis, because an internal lift of that height causes heel slippage and shoe fit failure.

Flexible pes planus is managed with a medial arch shell plus an intrinsic rearfoot post of roughly 4 to 6 degrees; a rigid flatfoot is accommodated, not corrected.

Positive model modification: add plaster for arch fill, grind reliefs over bony prominences, and smooth the model before vacuum forming so pressure areas are built into the shell.

Polypropylene 3 to 5 mm thick is vacuum formed at approximately 350 to 400 degrees Fahrenheit and must cool fully under vacuum to prevent warping.

Typical multi-density layup: rigid base shell (polypropylene or carbon), mid-layer cushion (PPT or Poron), top cover (Plastazote or leather).

Trimlines run medially to the first metatarsal head, laterally to cover the fifth metatarsal base, with heel cup height just below the malleoli unless more control is needed.

Break-in schedule: 1 to 2 hours on day one, increasing 1 to 2 hours daily; redness persisting more than 20 to 30 minutes after removal indicates a modification is needed.

Shoe fit is measured weight bearing at the end of the day: 3/8 to 1/2 inch of toe space, shoe widest point matching the first and fifth metatarsal heads, snug heel counter.

Dispensing check: no blanching, no focal pressure on metatarsal heads, toes clear the toe box, and the patient can don and doff the device independently.

Shell edges contacting the navicular, malleoli, or fifth metatarsal base are flared or ground to remove focal pressure before delivery.

Standard recheck occurs about two weeks after dispensing, then annually, and at any report of skin change, pain, or altered gait.

Diabetes: inspect both feet at every visit and at each footwear replacement; therapeutic shoes and inserts are renewed annually under most coverage policies.

Charcot surveillance: an interfoot skin temperature difference greater than 2 degrees Celsius suggests active inflammation and calls for immobilization and referral.

Pediatric reassessment occurs every 3 to 6 months because growth alters fit; shoe size is re-measured at each visit along with the orthosis.

Expected service life: foam and EVA devices 1 to 2 years, rigid thermoplastic devices 3 to 5 years, leather uppers roughly 12 to 18 months under heavy use.

Ulcer follow-up tracks area and depth serially; healing that stalls over 2 to 4 weeks prompts reassessment of offloading and vascular status.

Follow-up documentation includes pain score, activity level, skin integrity, wear time, and every adjustment made to the device.

The Medicare therapeutic shoe benefit covers one pair of shoes and up to three pairs of inserts per calendar year for eligible beneficiaries with a physician certification and order.

The KX modifier on a claim attests that the clinical documentation on file supports medical necessity for the billed device.

An Advance Beneficiary Notice must be issued before furnishing an item likely to be denied as not medically necessary so the patient accepts financial responsibility.

PDAC reviews manufacturer documentation and assigns the correct L-code; claims submitted with an unverified code are subject to denial and recoupment.

Required documentation elements: presenting history, physical findings, diagnosis, functional limitation, device description with rationale, and patient response.

Record retention follows state and payer rules; a common standard is at least 7 years, and longer for records of minors.

C.Ped scope covers footwear and foot orthoses below the knee; fabricating or fitting higher-level orthoses or prostheses requires separate O&P credentialing.

The HIPAA minimum necessary rule limits access, use, and disclosure of protected health information to what the specific purpose requires.