A News Story About Orthotics

Orthotics.JPG
A News Story About Orthotics
By Bob Neinast, a.k.a., Ahcuah

There was a story in the New York Times last week about the relative ineffectiveness of orthotics.

It seems that they often don’t do much.

The first story, published on January 18, is Close Look at Orthotics Raises a Welter of Doubts. It highlights Professor Benno Nigg at the University of Calgary. Here’s the money paragraph from the article:

His overall conclusion: Shoe inserts or orthotics may be helpful as a short-term solution, preventing injuries in some athletes. But it is not clear how to make inserts that work. The idea that they are supposed to correct mechanical-alignment problems does not hold up.
Of course, orthotists are up in arms (or would that be “up in feet”?). From the article:

The key measure of success, said Jeffrey P. Wensman, director of clinical and technical services at the Orthotics and Prosthetics Center at the University of Michigan, is that patients feel better.
If all that is measured is “feeling better”, that could just be the placebo effect, which is all about unquantifiable feelings.

That is not to say that orthotics are useless. There have been studies that show, for instance, that the right one (semi-rigid sole, not soft sole), can help reduce tibia stress fractures among military recruits. There are also studies showing that they help with plantar fasciitis.

The point of the article seems to be that orthotists all disagree as to what really works (and there are no studies supporting one particular type in a specific situation). Each orthotist has his own “style” of orthotic. As the article says:

Every new podiatrist or orthopedist, he told me, would invariably look at his orthotics and say: “Oh, these aren’t any good. The lab I use makes much better ones. Your injury is probably linked to these poor-fitting orthotics.”
Of course, the thing that I’ll note is that none of the studies compare the orthotic to bare feet. What they do is look at one odd distortion of the human foot and compare it to some different odd distortion of the human foot. I say this because any shoe makes some sort of distortion. A heel changes angles and stresses; a rigid or semi-rigid sole prevents all of the muscles, tendons, and ligaments from moving freely. Even things like Vibrams remove tactile information.

It’s as if society dictated we should all wear space helmets, and the helmetists spend all their time trying to add something to the space helmet to remove the distortions from looking through the bubble. They spend their time affixing various combinations of lenses to the inside of the helmet. And they also all say, “But you cannot go without the space helmet. You could hit your face on overhanging tree branches! What if a bird drops a rock on your head?”

I’m sure there are times that orthotics can be helpful (just as I am sure there are times that it is helpful to put your arm in a sling). But it sure seems that they are all to often a hammer looking for a nail.

http://ahcuah.wordpress.com/2012/01/26/a-news-story-about-orthotics/
 
What concerns me is that most doctors never seem to take into account what type of shoe an orthotic is being placed in. I would think the plane of the shoe, the heel to toe ratio, drop, would have an affect on the effectiveness of an orthotic. Most people don't have the money to have several sets of orthotics made according to the type of shoe they are going to be worn in. They cost $300 - $400 on average.

The ones I purchased were $300. They were custom-casted from my own feet. They were made to correct Morton's Neuroma, or to take the pressure (compression) off the areas I was having pain. All they did, for my $300, was make my MN pain worse, AND they caused my knees to hurt so that I had to ice after every run.

So, why don't insurance companies pay for them? I mean, if our feet are so defective from birth or living, then just like any crutch or cast, wouldn't we need them? I think they're not covered by insurance because they know historically, statistically, that they don't work.
 
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So, why don't insurance companies pay for them? I mean, if our feet are so defective from birth or living, then just like any crutch or cast, wouldn't we need them? I think they're not covered by insurance because they know historically, statistically, that they don't work.

You might find this article of interest:

http://www.fsco.gov.on.ca/en/auto/autobulletins/archives/Pages/a-05_98-3.aspx

As many insurers are aware, there have been increasing claims for orthotics in recent years. In fact, some insurers have experienced exorbitantly high claims for orthotics and many were prescribed by people who do not normally treat feet as a specialty. Research by the Ontario Podiatric Medical Association demonstrated that there were a number of retailers, and others who were regularly recommending orthotic devices, regardless of whether a diagnosis was made. Some people were selling orthotics literally off the back of a truck, while others would go into a company and screen all the employees recommending most or all would need orthotics and orthopaedic shoes.

By the 1990s, it seemed that just about anyone who had anything to do with health care was getting into the foot business and was recommending orthotics. Chiropractors, physical therapists, pedorthists and others were having patients step in a foam box, then dispensing basically a stock item arch support with or without modifications and calling it an orthotic device. They seemed not to understand that a foam impression of the foot is capturing the foot in a deviated or deformed position and is not corrective. Hence, problems would persist or recur.

The whole thing is worth reading.
 
Thanks. I've copied the link to my list of material to read. sigh. Good stuff!
 
Regarding foot orthotics, I recommend these to many of our patients since their problems are from asymmetry of the body and the mal adaptive response resulting in conditions of back, neck, shoulder and even knee and hip problems which are amplified in the runner as well as in other athletes. In my book, Cheating Mother Nature, what you need to know to beat chronic pain, it suggests the use of orthotics or footwear with built in support (Teva, Reef are a couple of well known brands, there are many more) should be used to counteract the problem of asymmetry, and then we retrain the body around the enhanced stability of the body so the person in essence cheats mother nature or cheats the system.

I totally agree that orthotics have been bastardized and most podiatrist I deal with have a one size fits all philosophical dogma that often fails because they look at the foot, but forget about the rest of the body. They often recommend an orthotic device that will fit one shoe, and rarely think about how the person will wear them and how they live.

I was trained by a pedorthist who still makes our foot orthotics for us. We generally recommend two custom styles and then a bunch of off the shelf orthotics are recommended including brands such as superfeet and powerstep. This gives us a wide pallet to choose from while making a recommendation. Generally, those with flexible arches and very flat feet will need custom because they will not tolerate the correction built into many of the off the shelf inserts. This is partially because of tight calves, and tight fascia in the back of the knee which is an adaptive response to the flat inefficient foot that toes out. In cases such as this, these patients will do best with a custom device because they will flatten out the off the shelf ones if they tolerate them.

If someone is mild to moderate with overpronation and foot flare, if the run many miles, and I give them an off the shelf insert, it is likely they will destroy them in three months or less. If the device I am giving them costs for instance $55, and we have to replace them four times per year, their cost will be over $200. In this case, a custom orthotic at $365 that can last up to five years makes more sense. On the other hand, if for instance a woman runs alot, and is in low pumps or boots most of the time, a different type of custom orthotic would be needed since this allows flexibility and she can wear what she wants to wear. If she wears shoes with 2 inch heels or above, an orthotic is not needed because that, believe it or not will correct for overpronation and create symmetry, however, it is not the ideal since there is no normal gait pattern with high heel shoes. On the other hand, if she is active 3x per week in sneakers and the rest of the time she is in low pumps, I may suggest a custom for the low pumps, and an off the shelf for the sneakers.

Basically, I custom tailor this to the persons lifestyle, with good effect. The person is also told to wear sandals and flip flops with arches. (http://www.backfixer1.com/blog/show...reat-summer-footwear-that-prevents-back-pain/)

The point I am making is that for orthotics to be worth anything, they have to fit the persons lifestyle and the doctor cannot use one size fits all as their method. Also, the patient needs to understand that the orthotic is just a brace under the foot to help create and maintain symmetry, and for maximal effect, fascial release to undue the years of accommodation to poor body mechanics. The devices, and the retraining is the way to get the desired effect, which is symmetry, less pain, and the ability to be athletic without being in pain and paying for the privlege. It makes no sense to hand someone one orthosis, not fully explain to them why they have pain and then have them uncorrected in their other footwear.

For a better understanding of this concept, read Cheating Mother Nature, what you need to know to beat chronic pain.
 
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It's remarkable that all living things are quite uniquely adapted to their environment. It's made me wonder if some human ailments are products of modern times.

For instance, there is research to suggest the myopia is related to lack of exposure to sunlight. This makes sense, as otherwise how would people have historically managed without glasses? The same applies to smog and asthma and obesity and junk foods.
http://www.cnn.com/2011/HEALTH/06/01/myopia.causes/index.html

I wonder if some runners' problems may be related to the running surface. Were there as many problems before the world was paved over with asphalt and concrete? Were shoe inserts found preserved in ancient Egyptian crypts, or is it more of a modern invention to deal with a modern problem? Are shoe inserts really needed on a natural surface? Do indigenous peoples pad their handmade footwear to account for anatomical discrepancies?
 
Good thoughts, Sid.
 

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