As baby boomers age and continue to participate in sports, more and more are suffering from foot injuries, such as plantar fasciitis and hallux valgus. And researchers have proposed the inserts as treatments for back, hip, knee and ankle ailments, as well.
Laird Harrison, Medscape Orthopedics May 26, 2016
|A Booming Business|
If you make foot orthotics, you can expect an exploding business in coming years. As baby boomers age and continue to participate in sports, more and more are suffering from foot injuries, such as plantar fasciitis and hallux valgus. And researchers have proposed the inserts as treatments for back, hip, knee and ankle ailments, as well.
But as the market swells, it is running into a countertrend: the argument advanced by kinesiologists that movement training and physical therapy provide better solutions to the problems for which foot orthotics are prescribed.
The controversy can make it hard for orthopedists to know which patients to refer to which specialists.
The market for foot orthotics reached $4.7 billion in 2015 and will continue to grow rapidly at least through 2021, market analysts say. “The crucial driving factors accelerating the market are rapid increase in aging population; high incidence of chronic diseases and disabilities and rise in sport injuries,” according to a report by IndustryARC.
Patients can find an array of prefabricated orthotics available over the counter, or they can have custom orthotics made. Although custom orthotics used to require casts of the patients’ feet, digital scanners have now made it easier for a wide range of practitioners to offer them, and some shoe stores are selling them.
|How Orthotics Work|
By affecting the way people stand and move, foot orthotics might change the pattern of forces and stresses throughout the musculoskeletal system. They provide one of the mainstays of treatment for plantar fasciitis and some types of metatarsalgia. They are often prescribed for hallux valgus and have been studied for ankle instability.
Excessive foot pronation might cause excessive internal rotation of the lower limb, resulting in strain at both the sacroiliac and lumbosacral joints, according to a recent literature review. Although few randomized controlled trials have put orthotics to the test as a way of correcting this problem, the US Veterans Administration recommends them as a treatment for work-related low back pain.
Lateral-wedged insoles can reduce the peak knee adduction moment and thus medial compartment loading of the knee, and have been proposed for treatment of knee osteoarthritis.
In one uncontrolled study, 67 older adults reported that arch supports, on average, reduced pain in their hips, backs, feet, and knees.
“I get a lot of referrals for hip pain, knee pain, and back pain,” says Jeffrey DeSantis DPM, an Orange County, California, podiatrist and trustee for the American Podiatric Medical Association. “It’s usually patients who are overpronators.”
He is happy to reassure patients that contemporary foot orthotics are softer and more flexible, and thus more comfortable, than those made in decades past. Some patients can get satisfaction with prefabricated orthotics, but many are better off with the custom-made variety, he says.
|Disagreement About Benefits|
But not everyone is ready to hop onto the orthotic band wagon. Foot orthotics often don’t correct the underlying biomechanical problems that cause the pain and dysfunction for which they are prescribed, says Heather Vincent PhD, director of the University of Florida Health Performance Center in Gainesville.
“Orthotics are not a permanent fix, and they are not really necessary unless you have an anatomical difference, such as a leg-length deformity,” she says.
Recent research has convinced her that people can reduce or eliminate their musculoskeletal pain by adopting movement patterns more like those for which the human body evolved before supportive shoes and orthotics were invented.
According to this line of thinking, shoes might cause much common pain and athletic injury by forcing feet into unnatural positions. Dr Vincent particularly cites narrow toe boxes and thick heels.
By the same token, orthotics can actually worsen the conditions they are meant to treat if they are worn too long, she says. “The foot doesn’t have the full range of motion,” Dr Vincent explains. “The bones and the muscle in the foot are not being activated the way they should, so the foot gets weaker and weaker over time.”
Alleviating knee, hip, or back pain with foot orthotics might simply shift the stress to a different joint, causing new pain there, she says.
Some studies have shown that forces are distributed differently in people running barefoot compared with people running in conventional shoes, suggesting a greater risk for some common injuries.
Researchers have documented weakness in various foot muscles in people with plantar fasciitis, suggesting that strengthening exercises might help.
|Gait Retraining: A Better Solution?|
up the kinetic chain, some research has shown that gait retraining may reduce pain and enhance function. For example, researchers at Ohio University in Athens were able to reduce patellofemoral pain in female runners by training them to improve their lower-extremity alignment.
Dr Vincent puts this information to work by analyzing what has caused her patients’ pain.
“Some of the best and most meaningful information comes from getting the patient’s history,” she says. She starts by asking whether anything has changed in the type, volume, or intensity of the exercise the patient is doing, and whether they have recently changed shoes.
She next uses a 3D motion-capture system similar in technology to those used by video game developers and animation studios and a force-plate template to analyze the way the patient moves. On the basis of her findings, she may recommend gait retraining, strengthening, and flexibility exercises. “We have to get patients to a place where they can run more naturally,” she says.
Dr DeSantis counters that this approach might work for young, fit runners, but he’s not so sure that it can help many of his patients, who are overweight and middle-aged. “In those type of people, I think a minimal shoe would be a mistake,” he says.
His own experience has taught him that making a custom orthotic can fairly quickly provide relief for a lot of his patients’ pain. And once they are out of pain, they often don’t want to give up their orthotic, he says.
|Overlapping Schools of Thought|
Thankfully, the two schools of thought overlap in crucial ways. Dr DeSantis is willing to accept that strengthening and flexibility exercises have a role for most patients. “In almost all of them, I would think physical therapy is an integral treatment,” he says.
And Dr Vincent can accept that foot orthotics have their role in taking pressure off temporarily until the right training regimen can address the underlying problem.
Between the two positions, perhaps a clinical way forward can be glimpsed for common musculoskeletal complaints: foot orthotics to address the problem in the short term, with exercise, stretching, and movement retraining as the longer-term prescription.
Source Medscape Orthopedics
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- Orthotic devices market analysis: by type (knee braces & supports, ankle braces & supports upper extremity braces & supports and others), by application (injuries, chronic diseases, disabilities, pediatrics)—with forecast (2015-2020). IndustryARC. July 15, 2015
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- Clinical Practice Guideline for the Management of Low Back Pain or Sciatica in the Primary Care Setting, Veterans Health Administration, Department of Defense. Washington, DC: US Department of Veterans Affairs; 1999.
- The effect of orthotic devices on knee adduction moment, pain and function in medial compartment knee osteoarthritis: a literature review, Baghaei Roodsari R, Esteki A, Aminian G, Ebrahimi I, Mousavi ME, Majdoleslami B, Bahramian F. Disabil Rehabil Assist Technol. 2017 Jul;12(5):441-449. doi: 10.3109/17483107.2016.1151952. Epub 2016 Mar 15. Review.
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- Prospective comparison of running injuries between shod and barefoot runners, Altman AR, Davis IS, Br J Sports Med. 2016 Apr;50(8):476-80. doi: 10.1136/bjsports-2014-094482. Epub 2015 Jun 30.
- Plantar fasciitis and the windlass mechanism: a biomechanical link to clinical practice, Bolgla LA, Malone TR. J Athl Train. 2004 Jan;39(1):77-82.
- Mirror gait retraining for the treatment of patellofemoral pain in female runners, Willy RW, Scholz JP, Davis IS. Clin Biomech (Bristol, Avon). 2012 Dec;27(10):1045-51. doi: 10.1016/j.clinbiomech.2012.07.011. Epub 2012 Aug 20.
Effect of foot orthotics on single- and double-limb dynamic balance tasks in patients with chronic ankle instability. Sesma AR, Mattacola CG, Uhl TL, Nitz AJ, McKeon PO. Foot Ankle Spec. 2008 Dec;1(6):330-7. doi: 10.1177/1938640008327516.