Defending My Position On Orthoses
- Nicholas A Campitelli DPM FACFAS
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Our profession needs to keep an open mind in regard to shoes and treating running injuries. People do not change what they are doing unless they have a reason to change. I continue to see runners not responding to orthotics and stability control shoes in my practice so I have provided a change, one that is working for others and myself. Of course, there is not a preponderance of evidence to support this change but there are emerging studies that support my thinking regarding the use of minimalist shoes. I have cited these studies in the past and will continue to do so. If the prior literature on orthotics were conclusive about their effectiveness, I would not be so strong-minded in my approach. I still feel there is a lack of clarity and consensus in the literature to support the use of orthotics.
Can orthotics work? Absolutely. How and what exactly do they do? It is very difficult to prove given the variability of one’s form, training pattern, shoe gear, strike pattern, biomechanics, body weight, training intensity and change in surfaces. My stance is that orthotics can treat an injury but this is a very haphazard approach. I think they are a crutch for treating the underlying problem, which may be overuse, poor form, weak musculature or improper training patterns.
I use orthotics in my practice, albeit rarely. I have found that by spending more time educating my patients on proper training patterns, form, foot strike, surface consistency, strengthening and shoe gear, I can make more of a difference in improving their injury. It can be more time consuming and challenging, but very gratifying. I do not encourage patients to discontinue using an orthotic if it is working for them. Again, I find this is very rare in my practice as most of the patients I see have already failed this type of therapy. The same applies to traditional running shoes. Many of the runners I train with wear traditional running shoes (yes, even ASICS) and I do not persuade them otherwise if it is working for them.
I love running, podiatry and making a different in people's lives. I am trying to change the way we think of feet in our society. We live in a society that has the stigma that we need to support and cushion our feet, which has yet to be proven. Shoes have evolved with no basis of evidence as to why a raised heel is present among many other features. I encourage others to be open-minded and consider my approach. I certainly have leaned more about orthotics and minimalist shoes as a result of being challenged by my colleagues. Thank you for stimulating my interest and encouraging me to read more.
Reviewing The Research On Orthoses
In regard to providing references to reinforce my opinions, I have done so in the past. Remember, I am speaking in regard to a paradigm change. We only have so much published on the new treatment and approach to running injuries as well as everyday foot pain and leg pain.
However, there is literature, both past and current, to support my opinions. Richter and colleagues conducted a meta-analysis of 23 randomized controlled trials on the use of orthotics for lower limb overuse conditions.1 The authors noted that the evidence does support using orthoses to prevent a first incident of lower limb overuse conditions but their meta-analysis found no difference between custom and prefab devices. The study authors noted “the evidence was insufficient to recommend foot orthoses (custom or prefabricated) for the treatment of lower limb overuse conditions.”
In looking at the efficacy of foot orthotics in the treatment of knee and hip osteoarthritis in 2008, Gelis and colleagues found “no evidence of a structural or functional impact on osteoarthritis (Grade B).”2 The authors also noted “no validated indication for prescribing foot orthotics in the treatment of knee or hip OA.”
We have even seen authors challenge Root’s philosophies. McPoil and Cornwall found that contrary to Root's published theory, the “neutral” position of the rearfoot for the typical pattern of rearfoot motion during the walking cycle was resting standing foot posture rather than the subtalar joint neutral position.3 McPoil and Hunt further challenged Root's theories on evaluation and treatment, and suggested an alternative “tissue stress model” for assessing and managing foot disorders.4
While Jarvis and colleagues noted the importance of static biomechanical assessment of the foot, leg and lower limb, they found that the key examinations physicians use to assess dynamic foot function and determine orthotic prescription are “unreliable.”5
Further Insights On The Relevant Literature
Several studies showing beneficial effects for orthoses were subjective in the form of surveys sent to patients.6-8
Gross and coworkers looked at 15 people with plantar fasciitis and found they could walk 100 meters with less pain by wearing an orthotic.9 This was not a long-term follow-up and in fact, the longest amount of time of wearing the device before testing was only 17 days. The study authors conclude that “custom semi-rigid foot orthotics may significantly reduce pain” during walking but these results were also subjective as they were based on patients rating their pain with the visual analogue scale and completing a questionnaire.
In a retrospective review, Saxena and Haddad looked at 102 patients with patellofemoral pain syndrome who wore orthotics and used multiple other modalities.10 They found 76.5 percent of the patients improved at the follow-up visit. Although the authors noted the use of semi-flexible orthoses was significant, we can make no direct correlation to the orthotic device given that the treating physicians used multiple modalities for these patients.”
Kilmartin and Wallace reviewed the literature to assess biomechanical foot orthoses in the treatment of lower limb sports injuries.11 In the article abstract, they note that “a review of the literature indicates that biomechanical orthoses will reduce rearfoot movement, but the effect on knee function is negligible and the clinical significance of excessive rearfoot movement is yet to be proven.”
Shih and colleagues looked at 24 runners with a pronated foot and knee pain who experienced pain relief with a medial wedge orthotic while running on a treadmill for 60 minutes.12 The follow-up was at two weeks so it difficult to draw any long-term conclusions from this study.
In a cohort-controlled trial, Ferrari examined the efficacy of orthotics in the treatment of trochanteric bursitis.13 He noted a 90 percent improvement in patients who received orthotics and a corticosteroid injection to the trochanteric bursa with fluoroscopic guidance in comparison to a 40 percent improvement in patients who had the injection only over a four-month period. Essentially, this study suggested that the placement of a rigid device in a shoe may facilitate pain relief for those with hip pain. How?
In a 2011 randomized, controlled trial involving 400 military trainees, Franklyn-Miller and colleagues demonstrated a 10-time reduction in medial tibial stress syndrome and a 7-time reduction in chronic exertional compartment syndrome with the use of orthoses.14 Overall, the authors noted an absolute risk reduction of 0.49 with the use of orthoses. However, it was not clear from the study how the orthoses were preventing injury and what the devices were doing from a clinical standpoint.
In contrast to this study was another study published in 2011 by Mattila and colleagues, who looked at the role of orthotic insoles in preventing lower limb overuse injuries.15 In this randomized, controlled trial involving 228 patients, they found that the “use of orthotic insoles was not associated with a decrease in lower limb overuse injuries.”
In another randomized, controlled trial involving 179 patients, Collins and coworkers examined the use of orthoses and physiotherapy for people with patellofemoral pain syndrome.16 While patients perceived foot orthoses as being superior to flat inserts, the researchers found no significant difference in combining orthoses with physiotherapy. In other words, adding orthotics to the physical therapy already prescribed produced no further improvements. This study demonstrated that active therapy can improve patellofemoral pain without relying on a permanent orthotic device.
In 2011, Mills and coworkers examined the short-term efficacy of orthoses in patients with anterior knee pain.17 This was a extremely short-term study of six weeks involving 40 patients with patients subjectively classifying an improvement in symptoms with prefabricated orthotics in comparison to no treatment at all.
What The Literature Reveals About Stress Fracture Risk
Assessing both semi-rigid and soft orthoses in the prevention of stress fractures in military recruits who wore “infantry boots with soles designed like those of basketball shoes,” Finestone and colleagues found that 10.7 percent of patients with soft orthotics developed stress fractures, 15.7 percent of patients with semi-rigid orthoses developed stress fractures and 27 percent of the control group developed stress fractures.18 It is interesting to see the high rates of stress fractures in all three groups in this study in comparison to the reported average incidence of stress fractures occurring in runners. Tenforde and colleagues reported a stress fracture incidence ranging between 4 to 5 percent in adolescent runners.19 Tuan and coworkers noted a stress fracture incidence rate between 4.4 to 15.6 percent in athletes.20
Researchers have also demonstrated a 3 to 6 percent reduction in stress fracture risk by shortening your stride.21 Shortening one’s stride is associated with minimalist shoes, which were proven to reduce strike impact in a recently published study.22
The studies I discussed above are not selective representation of articles to support my opinions. My opinions are based on some of the articles and research provided by Kevin Kirby, DPM, in response to my last blog (see http://www.podiatrytoday.com/blogged/can-minimalist-shoes-be-beneficial-... ) as well as the research and literature I have read and continue to read.
In summary, my opinions on the use of orthotics for treating runners are based on the lack of definitive evidence as to their exact role. This leads me to be open-minded in my approach to treating running injuries. There is an enormous amount of variance in factors that can contribute to running injuries and the aforementioned studies seem to raise more questions than they answer on orthotic intervention.
For example, to rely on symptoms of greater trochanteric bursitis improving after wearing a shoe orthotic does not render any evidence as to why. Of course, we can see gait changes by using an orthotic but we can also see gait changes in runners by implementing a more natural style of running which involves landing at or near below the center of gravity of the body on the midfoot. Striking in this manner all but negates the need for any orthotic because there is minimal concern on controlling rearfoot motion. I have yet to see any study comparing orthotics to using a midfoot or forefoot strike pattern along with improved running form for treating injuries.
We need to collectively move forward with progressive thinking and challenge new and old theories. My opinions are based on current and past literature, and are not biased in regards to any shoe company, specifically Vibram USA.
In regard to my alleged ulterior motive to market FiveFingers shoes (Vibram USA), they are and continue to be a training tool for me in running. Having the opportunity to sample running shoes, I tend to train and run in a lot of different types of shoes. I recently ran a marathon in a pair of New Balance RC5000s. However, to be clear, I have no financial interest in any of the shoe companies.
It is very disheartening to see my colleagues belittle my attempts at progressive treatment options that are in current use to treat runners. We can see that as a result of the popularity of minimalist shoes as well as the lowering in heel height of traditional running shoes, a change has occurred in the running shoe industry. In my clinical experience, those involved in the sport of running are now beginning to focus more on form than on footwear itself. This is changing the way we all run and will soon change podiatry for the positive.
Editor’s note: Dr. Campitelli has disclosed that he is an unpaid Medical Advisor to Vibram USA.
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2. Gélis A, Coudeyre E, Hudry C, Pelissier J, Revel M, Rannou F. Is there an evidence-based efficacy for the use of foot orthotics in knee and hip osteoarthritis? Elaboration of French clinical practice guidelines. Joint Bone Spine. 2008;75(6):714-20.
3. McPoil T, Cornwall MW. Relationship between neutral subtalar joint position and pattern of rearfoot motion during walking. Foot Ankle Int. 1994;15(3):141-5.
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12. Shih YF, Wen YK, Chen WY. Application of wedged foot orthosis effectively reduces pain in runners with pronated foot: A randomized clinical study. Clin Rehab. 2011; 25(10):913-923, 2011.
13. Ferrari R. A cohort-controlled trial of customized foot orthotics in trochanteric bursitis. J Prosth Orthotics, 2012;24(3):107-110.
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15. Mattila VM, Sillanpää PJ, Salo T, Laine HJ, Mäenpää H, Pihlajamäki H. Can orthotic insoles prevent lower limb overuse injuries? A randomized-controlled trial of 228 subjects. Scand J Med Sci Sports. 2011 Dec;21(6):804-8.
16. Collins N, Crossley K et al. Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomised clinical trial. Br J Sports Med. 2009; 43:169-171.
17. Mills K et al. A randomised control trial of short term efficacy of in-shoe foot orthoses compared with a wait and see policy for anterior knee pain and the role of foot mobility. Br J Sports Med. 2011;46:247-252.
18. Finestone A, Giladi M, Elad H, et al. Prevention of stress fractures using custom biomechanical shoe orthoses. Clin Orth Rel Research. 1999;360:182-190.
19. Tenforde AS, Sayres LC, Liz McCurdy M, Sainani KL, Fredericson M. Identifying sex-specific risk factors for stress fractures in adolescent runners. Med Sci Sports Exerc. 2013 Apr 11 (Epub ahead of print)
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22. Giandolini M, Horvais N, Farges Y, Samozino P, Morin JB. Impact reduction through long-term intervention in recreational runners: midfoot strike pattern versus low-drop/low-heel height footwear. Eur J Appl Physiol. 2013 Apr 14. (Epub ahead of print)