Does Everyone need Insoles?

Wholeheartedly seconded. At best its spam. At worst its trolling. And it crops up on ever single thread whether its a barefoot one or not. Some have some valid arguments to make but most trot out BS they made up on the spot (nerve superhighway) or stuff which palpably makes no sense, like the inference that since we were born without shoes, this is the best way to be.

You were also born naked, helpless, mindless and covered in **** barry, but one hopes you can realise that this is not the most healthy way for an adult to function. Then again, perhaps this is "primal blogging" and you are. Its so much more NATURAL than typing clothed, clean and in a house, so it must be better right?

 

YES PLEASE!!!!!!!

 

We need Barry Onion et. al. to stimulate debate.

BTW Didn't Leonardo de Vinci say the human foot was a miracle of engineering. :sinking:

 

[Sigh] Monsieur L'Oignon,

I can only echo the sentiment of my colleague; "If you're a podiatrist Barry, you should know better. If you're not, you really should not be here."

You obviously missed this when you signed up for this forum;

 

This is Barry Onion's last post.

Goodbye and goodluck. :santa:

 

Bye bye Barry. As we can all see, wearing shoes makes onions cry. This is why Barry is so anti-shoes.

 

This was easy... almost to easy....

 

Thats because as we all know, barry was but one head of the hyduhra, the many headed moron of greek mythology. Slice off one head (or ask and see it have the good grace to bog off by itself) and 2 more will grow back in its place.

 

Me think Barry just had a lot of fun baiting folk, really.

Best to just let them bait then starve them of response.

Excluding those who may actually have something in what they say of course.

 

You need to look up the 'appeal to nature fallacy'. Appealing to nature as part of an argument is a fallacy and flawed. Since when is something good just because it is natural? Arsenic is natural, is that good? Most pharmaceuticals are not natural, are they bad?

 

I'd recommend this book to all. It lists and explains fallacies commonly used in academic debate.

http://www.amazon.co.uk/The-Book-Fallacy-Intellectual-Subversives/dp/071020521X

It was republished under this (cheaper) title:
http://www.amazon.co.uk/How-Win-Eve...1?s=books&ie=UTF8&qid=1333566494&sr=1-1-spell

 

THANKS. I had not seen that one. Already orderd a copy. My favourities are:

Currently working through Junk Science Judo by Milloy

 

I was hoping he would explain how natural it is to be living into your 90's with feet that have very little chance of being pain free with support and protection.....and how going barefoot would help these unnaturally old folks.....kept alive way beyond their natural span by beta blockers, statins and ACE inhibitors......just so unnatural for all of us, things were so much better when the average life span was 47.
regards Phill Carter

 

Unfortunately there are also other factors that influence whether or not people get orthoses...Just like in any medical field...
1. Mood of practitioner
2.Bank account balance of practitioner
3.Some practices now use - Monthly targets of orthoses sold and targets for podiatrists to sell to meet running costs.
4.Pt's perception of insoles...

Unfortunately these factors should NOT influence whether or not someone gets orthoses...Podiatrists should have a focus of rehabilitation and reconditioning of the foot and ankle in addition to control of mechanics using footwear and orthoses...Having said this I would estimate that in reality only 10-20% of the total population needs orthoses and this is also in extreme circumstances or where orthoses could be used short-term prior to reconditioning of the foot.

Now, don't play the fool and pretend that these factors have not influenced your decision in giving a patient orthotics before..Be realistic and truthful people.

 

Shalom:

Who is playing the fool here? What evidence do you have to make these statements or are you just pulling them out of thin air? Do you have any clue at all about all scientific studies that show that foot orthoses are not only therapeutic but also positively change the kinetics and kinematics of the foot and lower extremity?

And, why don't you be a man and give us your real name and what your medical speciality is. Don't play the fool, Shalom.

 

Dear Dr.Kirby,

I too like yourself am a podiatrist. And Shalom means peace...And these statements come from a few years of clinical experience seeing 'foot specialists' prescribing orthotics in sound 'clinical judgement' using techniques such as the RCSP and NCSP to quantify prescriptions and scripts. I work at a practice where they sell orthoses to pay the bills and am ashamed to be working at such a place..

I dare say that you have long-term studies showing 'long-term effects of orthotics on people that you have given orthoses to' or that just because McPoil and Hunt et.al 1995's study on soft tissue theory says that 'where there is soft-tissue inflammation under plastic-load deformation'. I am not questioning your clinical judgement or your decision making in orthoses prescription but rather stating that these factors are what's driving podiatrists in their prescription of orthoses...Much like prescription glasses... It is mass marketing.

Also in your 25 or so of practice you have not had enough time to gauge long-term effects of insole prescription... It is unfortunate that when someone speaks of barefoot walking that they are kicked out of this forum...If there was a counter argument against this you should specify your case..And support the notion that 'when we were born we didn't have shoes on'

I am greatly interested to see where the literature in the next 10-15 years takes podiatry and its basis behind custom insole prescription.. Unfortunately any medical speciality that is influenced by monetary benefit (this included orthopaedic surgeons doing surgery for monetary gain, optometrists selling glasses for monetary gain) should be ashamed of this..Health care is not a business it is a service and a honour to be serving people not turning them into consumers.

Thanks,
Shalom (Peace)

 

Shalom:

You would get more miles out of your barefoot-loving message if you were confident enough of yourself to give us your real name so that others, including myself, could take you more seriously. Until you can step out into the light of day, Shalom, and give us your real name, then, honestly, you aren't worth any more of my time or worth having a discussion with.

Anachemowegan (Peace in Mohican)

 

"Shalom" (and I am with Kevin that if you do not reveal your name that you cannot expect to be taken seriously or expect any further responses),
1, 2 &3. Given that many of us here also dispense OTC devices and not based on mood but the clinical level of necessity, your opinion is a weak one at best.
4. I've had patients walk in asking me to make them an "orthotic" and my fees and sent them out the door or provided an OTC product and shoe recommendation on numerous occasions. I don't dispense based on a patient's perception that they "need" what I offer, their perception is not a factor and I educate them on ALL of their options as I am sure most of us do.

I agree in part with much of this. The problem is when we see a patient with acute PF for example and to suggest less support is contrary to what we already know and common practice. I know where you are going with this and there is no evidence that barefoot anything is a an accepted treatment for ANY foot condition. Foot orthoses and shoes do NOT weaken muscles, inhibit "proprioception" or contribute to muscle atrophy.

Facts are facts "Shalom". Your comments appear to be straw-man arguments to promote your own views and unless you can provide anything beyond anecdote proving otherwise are invalid. I am not against going barefoot or barefoot running, I walk around barefoot all the time but mostly wear shoes and my CFO's because I have had foot problems in the past and despite how nice barefoot feels (and that's all that it really is), know better than to test fate.

Never, period. I'm sure some do but then doctors perform a number of unnecessary foot surgeries every year and over prescribe antibiotics and statins. How do you suggest that we reign them in?

Are you more concerned for the patient or promoting your own paradigm?

Clinical practice guidelines and parameters are established for every profession and the majority follow them. I feel that it is the same for foot orthoses, much less so for retail stores but you appear to be suggesting that it is much more common for trained professionals. Again, where is your evidence beyond your own personal opinions?

 

"If we all worked on the assumption that what is accepted as true is really true, there would be little hope of advance."

This is just about all I agree with what you said my friend. You should pay a visit to podiatry practices around the country as a patient to witness what actually goes on.

 

Agreed. But the fact is that using statins you can monitor HDL,LDL,VLDL amounts in the body along with triglycerides and ACTUALLY show the pt that this reduction is having a positive impact on the body, there are numerous studies including the longitudinal Farringham study that PROVES this. And as for antibiotics, this is an internationally accepted issue and there are initiatives under way to combat this. This is what I call a 'staw-man argument'. And as for foot surgeries agreed! But I don't see anyone questioning orthotics....A general practitioner does not get extra money ($500-800) for prescribing statins or antibiptics to someone...A podiatrist does.It is a money making scandal and I stand by that statement and will argue that orthoses are only needed in 10-20% of cases where they are prescribed.

 

When the going gets tough........... one goes back to basics (to misquote Sherman Potter in MASH). What we need to remember here is the two basic underpins of medical ethics. Beneficence (do only good), and Non-Maleficence (do no harm). As with any other medical intervention, you should have these at the forefront of the decision making process. Does this patient need mechanical intervention? Will they benefit from it? And, am I certain (as one can be) that it will do no harm? When Macdonald and Kidd wrote their paper on this, perhaps in 1998, the expletives they received were not repeatable on this forum. Indeed one US Pod actually wrote in the US press saying (roughly) "how dare you criticise this - do you know how much money I have got invested in it"? At all points in the mechanical intervention process, just as any other medical intervention, these two key Principles should be at the forefront. Are they? Rob

 

I completely agree Dr.Kidd.

The question remains....Are they?

Thank you.

 

Actually I have visited a number of DPM practices in my area as the ones who do not provide orthotics are my market. The ones who refer these services out to a pedorthist such as me certainly aren’t part of the problem that you describe, on that we would agree?

And in the case of say a diabetic ulcer, which can have tragic consequences for the patient, can likewise be monitored for progress and clinical success validated as well. Another example is observing a dramatic change in gait, improvement in foot function and activities of daily living, a reduction in pain scores etc. in PF or PTTD with an appropriate CFO not just immediately but over time. Just because no blood test exists for CFO’s does not render them clinically of no value Shalom, we can record a patient’s progress both subjectively and objectively without blood tests. Physical medicine often must rely on the above, but in the PF and PTTD example a follow up MRI will confirm success as we can observe the soft-tissue as positive changes occur but is it even necessary as clinical outcomes support there is much greater benefit than harm? Where is the evidence of harm on the other hand, or is it merely perceived to be financial?

Since the advent of statin drugs, pharmaceutical companies have influenced the statin studies and thus the numbers to the fuzzy point where they’re now suggesting children take statins preventively (regardless of other factors such as cardiovascular risk and family history). I know physicians as well and I question all of my patients about their current medications. What I have found is that most of the prescribing of statins is not evidence-based but based on total serum cholesterol alone and that certainly turns a profit for the physician. Tell me, what harm has the over-prescribing of statin drugs caused?

Food for thought:

http://www.ahrp.org/cms/index2.php?option=com_content&do_pdf=1&id=432

Shalom none of us are naive, so I'm sure that in some cased you are correct. If, and this is a big "if", we relied on studies as absolute proof of every intervention we'd have a huge problem. The best evidence says overwhelmingly that foot orthoses work for a variety of conditions (both prefab and CFO), not absolute proof but statistically valid or the practice would have died out long ago I feel.

You raise some good questions Shalom, I don't disagree with some of what you say but a lot of it is opinion and you are entitled to yours as well.

Cheers :drinks

 

Thank you Sir, I agree!

Diabetic foot ulceration accounts for the 10-20% of cases where orthoses ARE the most effective form of off-loading to encourage healing.
However, in circumstances where orthoses have no benefit to the patient (Ie- No change in VAS scores, no changes to inflammation level and ADL) then I would warrant that orthoses are not working for this patient. It is unreasonable and unjustified for a practitioner to be persisting with orthoses if they are not getting clinical outcomes with orthoses use.

And I am also afraid to say that we do not know the long-term consequences of inserts/ orthoses to know well enough what we are actually doing to movement variability, range of motion and muscular competencies within the lower extremity. Until we have longitudinal studies investigating these factors as well as long-term pain and injury risk, we have no solid evidence and we are walking in the light of RCT's conducted (for 6-9 weeks as a mean duration on average) to quote our decision making and clinical judgement. This is where my statement on I would be very interested to see where foot and ankle literature takes us in the future stems from.

Also there is a trend now to achieve the 'optimal heel height for performance' by boosting patients heel lift's by up to 30mm. Basic biomechanical knowledge and compensation mechanics and long term adaptation strategies according to Davis Law postulates that this sort of treatment is uncalled for when we have no idea what ' the optimal heel height' is for patients. We are infact blocking Ankle joint ROM and potentially creating tendencies for injury by doing this..The evidence will come in the next 10-15 years of gastroc/soleus shortening. Lastly the next thing on the line is the pseudo-cavus...This is treated in the same way.

Where does the normal come from? In philosophy, especially that of Aristotle, the golden mean is the desirable middle between two extremes, one of excess and the other of deficiency...Are we infact using this principal? Where are our ideas of the 'ideal' stemming from? We cannot postulate that because 40-50% of the population does one thing that this is the best for the other 50%? These factors much like other aspects of medicine are dependant on race, height, weight, genetics, BMI, activity level, performance, affordibility...

As much as using so called 'biomechanical theory' we should also be using these factors to make our clinical decisions.

Thanks,
Shalom

 

I think you should bear in mind here that in other countries in the world, podiatrists and other prescribers of foot orthoses are not financially motivated as the health care is paid for by the state. It is therefore of no financial benefit to prescribe orthoses to treat pathology. In fact, there is probably a greater likelihood of health care providers trying not to issue orthoses due to financial constraints.

I practice both privately and for the health service and my motivations are no different as my reputation and integrity is key to my business. I am pretty sure I am not alone in this respect

Robin

 

This is a fair comment. IF you compare the private sector to the public sector anywhere in the world you would see that trend Robin. There would be more podiatrists prescribing orthoses in private practice compared to the public system for obvious reasons as financial restraints. But my experience has been that private practices are more likely to prescribe orthoses based on financial constraints and the need to pay the bills and to make profit, where the state would not ask podiatrists to 'sell more orthotics' so that we can pay our bills.

I am not questioning your integrity and motivation in prescribing orthoses, I am just making it clear to everyone that people know that there are podiatrists that prescribe for the wrong reasons, they are not stupid. So do not let it be something that is not out in the open..

Then the next question is...After having treated an acute phase of a condition (Ie- severs, plantarfasc, post tib tendinitis) how many people withdraw orthotic therapy from patients and how many continue to prescribe, re-modify and alter orthoses annually in patients that are healed? Take note I have mentioned some conditions that have a tendency to only occur once and after the natural progression of the disease, the patient can be said to be 'healed' from this 'pathology'

Comments, Queries, Problems?

 

Yes. Since when does an anonymous poster, who hides behind a made-up name on an academic website for health professionals, have the right to tell the rest of us that we should be "out in the open" about how we run our private practices? It seems rather odd to me that you, Shalom, expect all the rest of us to be up front and honest with you when you aren't man (or woman) enough to even give us your real name.

Maybe you can explain this paradox to the rest of those following along?

 

Hi Shalom,

Actually, I can sympathise with you wanting to be annonamous because you're afraid of speaking against your employer. I've been in that position myself, being pressured to sell orthotics. I hated it, and now I run my own practice I pride myself on prescribing orthoses ethically (i.e. no rip offs!). For example, I mostly use prefabs with kids if I can, as they grow out of them so quickly. And if someone has something which is likely due to crappy foowear and gasctrocsoleus tightness, guess what? I give them footwear advice and stretching exercises! And see them in a few weeks.

Regarding your comment above- i think your own cynicism about your own employment situation may be affecting the way you see the profession as a whole. Just because you believe your company is unethical doesn't mean we all are. Why don't you lease a shop, fitout a clinic, promote your practice and practice an ethically based podiatry practice? Be the master of your own destiny and practice how you want to.

Maybe you could quietly create a new profile and contribute openly on this forum? Or at least let us know what continent you live on, so we can understand a bit more the context of the health market you practice in.

Phil

 

Shalom
I understand what you are saying and I am sure there are unethical practitioners out there prescribing for the wrong reasons. I am also sure that the vast majority of contributors on this forum are not like that- the fact that they are spending a significant amount of time on this forum discussing theories and methodologies speaks volumes to me.

I am working in a clinic where I get paid the same no matter what my patient load is, or how many foot orthoses I make. As I do all my own design and manufacturing providing foot orthoses creates more work for me, not income. I find I use custom devices for the majority of patients because I feel they are the best solution for achieving my desired goals.
I know this is an uncommon situation, but I do not find myself operating any differently to when I was working privately in Australia. Either way I work with a clear conscience.

If there is a problem with the prescribing of orthoses is that there is not enough critiquing of the outcomes- If a practitioner has made the clinical decision that foot orthoses are warranted, then they have need to be able to assess whether they are effective, and be in a position to change them if they are not. I personally think a good rule is that follow up consultations are free of charge.

 

Shalom, you need to change your moniker to a name that means judgement as that is more fitting.

If you do not like where you are then leave. Open your own office. Make the world a better place on your terms. Stop judging others and start being your own man.

Shalom,

Steven

 

My take on Orthoses is that they should by theory only be implicated in the presence of a deformity in which the compensatory movement is causing pain/trauma. In the absence of deformity, movement dysfunction needs to be identified and addressed. The use of orthoses may be useful in this instance to alleviate acute symtoms over the short term, however they ideally would be removed as the movement impairement is addressed.

POtentially one could argue that if you only address the symptoms and don't address the movement dysfunction you'll simply get a compensation somewhere else within the kinetic chain and a new issue will arise. i.e. Instability at hips leadings to increased pronation at the foot. Throw an orthotic on to block or reduced excessive motion at the foot without addressing the hip dysfunction and you'll likely get issues at the knee.

I'd say the reason orthotics have become so widely used is because the "ideal patient" i far and few between, and for the most part Pt's simply want a quick resolution to their symptoms. Applying the tissue stress theory, you may never see a particular Pt again post orthotic intervention as their lifestyle hasn't pushed them beyond their biological tissue stresshold. On the other hand a competitive runner may be back in a matter of months complaining of knee pain. Many podiatrists would then resort to modifying the orthotic to be even more corrective.

You'll notice much of the threads here are based on joint mechanics and the application of physics and engineering to the structural components of the foot and ankle. What they often fail to acknowledge (in my opinion) is the importance of functional anatomy and the influence of motor control and muscle tension on the function of the skeletal system. For example you can study the intrcacies of the shapes and mechanics of a pupets wooden body but it's mostly irrelevant if you ignore the strings.

 

You presuppose that we were all built to function on a hard and flat suface - which is what most of us in the West do for most of the time. The key to human ambulation is adaptability, which is why we can ambulate, barefoot or shod, over hard, flat, undulating ans soft ground, not to mention trees and rock-faces.

Your post would make more sense if
a) our anatomy was such that we could all ambulate and support ourselves on hard, flat surfaces with no problems

and

b) we didn't have such a long lifespan.

 

Welcome.

What is a compensatory movement. What does it compensate for. Can you define what a movement imparement is?

Can you explain the mechanism of how hip instability causes "foot" pronation?

If you read the tissue stress threads some more you will see that the forces from the muscles are considered. What do you mean by functional anatomy? Can you provide an example of where someone talking about tissue stress has ignored anatomy?

Again, welcom to the arena. We love a good debate here. You have challanged my beliefs and I would enjoy defending them.

Eric

 

We call this: "dynamics". While my colleagues and I often use quasi-static analyses in our discussions here on podiatry arena in order to simplify the models and to aid in teaching and learning, such models include muscle forces and anatomy. Moreover, I don't know any of my peers who ignore dynamics in assessing and treating their patients.

 

MRC86:

It would be helpful if we knew your real name and if your are a podiatrist, physiotherapist or pedorthist/orthotist since many of us don't like taking the time to make lengthy replies to someone who doesn't want to divulge their real name in a public discussion.

You seem to be making some judgements of many of us here regarding what we consider and don't consider in our patients. My friendly advice is for you, as a newcomer, is to not assume what we consider or don't consider as to what we do in our practices since this will likely make you a target for many of us....I really don't think you want to go there.

 

Ok Kevin,

I don't think I actually requested a response to my post, it was simply my two cents. Thanks for the final comment you have made here, it will resonate with me long into my career.

Merry xmas and a happy new year,

mrc86

 

Barry Onion is back after a three year break and has lots of great news to report.

Indeed barefoot walking is a long term antidote to orthoses.

The Onion is living proof.

Pod docs should focus on foot mobilisations and switching on the lazy tibialis posterior once the orthotics have done their job of removing inflammation. Continued use of orthotics only leads to dysfunction at the knees and hips and puts the tib post out of action, akin to a cast on an arm. :good:

 

Welcome back; ... you do realize that anecdotes are not data or evidence.

So now maybe you can answer the question I asked you several times before and you never answered. How do you think we should treat posterior tibial tendon dysfunction without using foot orthotics?

A lot has happened in 3 yrs:
- the barefoot fad is all but over! (the fad was a boom for podiatrists in all the problems its created)
- orthotic sales are up
- all the research has shown foot orthotics do not weaken muscles (and two have shown they make the muscles stronger) ... so you spouting BS when likening them to a cast on the arm.

BTW, most podiatrists DO foot mobilisations!

 

Out in the country we are obviously behind the city, I am still getting people with self inflicted trouble from trying to convert to bare foot running. There is an evangelistic barefooter in my area.....he says it is right for everyone....you just have to push through the pain and suffering. Can't say as I agree.
regards Phill Carter

 

The sales of minimalist running shoes have declined every month for the last 18 or so months; now down to a 3% marketshare; the number actually doing true barefoot is a tiny fraction of that - it did not take over the world. The sales of the super padded/cushioning shoes like the Hoka's are sky rocketing. (In the USA, no one running shoe model has gone above about 3.5% marketshare in a day; on 1 Feb, the superpadded Brooks Transcend was released and achieved 7% marketshare for that day!). The fan boys are not happy, but runners are voting with their feet.

The bulk of the science has now come in and has clearly showed there are no generic benefits to it. The injury rates in runners are still the same. The fan boys are not happy and rolling out the usual trope of logical fallacies to justify their evangelism...... its like the doomsday preppers suddenly realizing that the doomsday that they hung there hat on did not happen ..... its really funny to watch and see the justifications.