Current Insights On The Benefits Of Custom Orthoses And AFOs

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Author(s): 
Guest Clinical Editor: Bijan Najafi, PhD

These expert panelists discuss the pros and cons of custom foot orthoses and their biomechanical benefits, whether ankle foot orthoses (AFOs) can prevent falls in older patients, and how to prescribe orthotics for older patients.

Q:

How we can explain the controversy regarding the benefit of custom foot orthoses for the management of foot pain?

A:

Although custom foot orthoses seem to be a patient-centric intervention for foot pain in comparison to prefabricated foot orthoses, Bijan Najafi, PhD, says the research does not show significant benefits of custom devices in comparison to prefab devices from a biomechanics standpoint. He asserts that this controversy is mainly due to the fact that those studies often consider change in peak pressure as a primary outcome and notes this may not be relevant to describe the biomechanical benefits of custom orthoses.

   Dr. Najafi notes custom foot orthoses reduce peak pressure via redistribution of plantar pressure while prefab orthotics often reduce peak pressure due to shock absorption. Biomechanically, he says there is a significant difference between these two phenomena since the first custom devices help to enhance dynamic plantar loading while the prefabricated devices reduce local peak pressure without changing the shape of pressure profile.

   Dr. Najafi cites a recent study revealing that with normal and healthy arches, the statistical distribution of plantar loading is similar to a Gaussian shape whereas in patients with a painful abnormal arch like pes cavus, this shape has far from a normal distribution.1 The authors proposed an index named dynamic plantar loading, which represents the self-similarity between plantar pressure probability distribution with a Gaussian shape.2 They demonstrated that custom orthotics can enhance the dynamic plantar loading index while prefab orthotics are unable to change this index.

   Karl Landorf, PhD, GradDipEd, DipAppSc(Pod), does not consider there to be much controversy about custom versus prefab devices. He notes randomized trials have found that both custom and prefab orthoses are beneficial for patients, and systematic reviews have found custom and prefab devices are beneficial for foot pain and can prevent injury in highly active people.3-5 However, Dr. Landorf warns that practitioners need to be aware of the evidence so they prescribe orthoses for appropriate conditions.

   Dr. Landorf says there is more controversy with trials that have compared customized orthoses to prefabricated orthoses. He notes many studies have found that appropriate prefab devices, appropriately contoured foot orthoses for example, are just as effective as custom orthoses for many conditions (e.g. plantar heel pain).6

   Those who understand pathomechanics have the option of incorporating orthotics into the treatment regimen for many maladies, according to Gene Mirkin, DPM. An orthotic can lessen or resolve pain, and he says success makes it easy to espouse the virtues of orthotics.

   On the other hand, Dr. Mirkin notes that when people do not buy into or understand biomechanical contributions to pain and injury, they have “a closed mind” and are not necessarily willing to try this approach, and therefore are naysayers about the benefit of orthotic therapy. He argues the cost of custom orthotics also comes into play for some of the non-believers of orthotic therapy, who may think of the devices as an expensive therapy that patients do not always need. Dr. Mirkin also says the reimbursement may motivate some providers to dispense them because the coverage is available.

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