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Are Custom Foot Orthoses Analogous to Orthodontic Braces, or Not?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Kevin Kirby, Sep 6, 2014.

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    In another thread on Pediatric Flatfoot Correction with Foot Orthoses I made the following statement:

    Then another podiatrist made the following reply to me:

    My belief is that custom foot orthoses and orthodontic braces are very closely related, medically-based mechanical treatments and, as such, my comparison of treating teeth with braces and children's flatfeet with custom foot orthoses is indeed, quite valid for the following three reasons:

    1. Both custom foot orthoses and orthodontic braces are custom-made appliances which are designed to apply precisely designed external forces to parts of the body in an attempt to align them more normally over time and allow more normal function of those body parts over time.

    2. Both custom foot orthoses and orthodontic braces are used by highly trained medical professionals who use their knowledge, training and technical skills to try and improve both the visual appearance and improve the biomechanical function of the body part they are treating.

    3. Both podiatrists and orthodontists use these devices on children and adults in an attempt to improve the lives of their patients, while, at the same time, attempting to do no harm to their patients by closely following these patients over the course of their treatments.

    Now what are the differences between orthodontic braces and custom foot orthoses?

    1. Orthodontists routinely recommend, prescribe and treat using orthodontic braces on asymptomatic children (i.e. those without subjective complaints) with tooth and jaw deformities and are considered caring, skilled professionals who are highly sought after and revered for their medical and technical skills.

    2. In some countries, podiatrists who recommend, prescribe and treat using custom foot orthoses on asymptomatic children (i.e. those without subjective complaints) with foot and lower extremity deformities, even though these children have abnormal gait patterns and/or have a strong family history of painful flatfoot pathologies, are considered to be unethical and are criticized and shunned by many of their podiatric peers for even recommending custom foot orthosis therapy for these children.

    Does this make sense to you? It doesn't to me.

    What say you?
  2. Craig Payne

    Craig Payne Moderator

  3. Craig Payne

    Craig Payne Moderator

    Just to clarify...
    - analogies are useful to explain things to people
    - they can't be used to argue a case

    ie what the Rational Wiki link above says:
  4. Craig:

    Here is the definition for a logical fallacy:

    Therefore, for my argument to be a logical fallacy, one must then show to all of us following along that one or some of the points of my argument are either "invalid" or "unsubstantiated assertions".

    From my knowledge of the medical professions, mostly here in the USA, but also internationally, my argument is not a logical fallacy, as you say. Please tell me which of my following points is either an "invalid point" or is an "unsubstantiated assertion" in order to support your claim that my argument is a "logical fallacy".

    In other words, Craig, which of the following are not true? I believe they are all very true.

  5. Griff

    Griff Moderator

    Don't disagree with number 3.

    Regarding 1 and 2: Are foot orthoses always given "in an attempt to align parts of the body more normally" or to try and "improve the visual appearance of the body"?

    Many great minds (your own included) have been successful over the years in encouraging much lesser minds (my own included) that this may not be the case...
  6. Your up awful late, Griff! I agree that the goal of the custom foot orthoses I use in treating children's flatfoot is more to decrease internal stresses within the foot than to improve the visual appearance of the foot. However, properly made custom foot orthoses often improve the visual appearance of the foot also (when they are wearing them), which makes the parents quite happy. In addition, we do have plenty of research that shows that foot orthoses can change the kinematics of gait. Why not give children with significant pathology, but who are not yet symptomatic, the benefit of the doubt and offer them treatment, Griff? What would you do with your own son if he were severely flatfooted and running clumsily, but complained of no pain? Just observe....or treat?
  7. Griff

    Griff Moderator

    Always up in the small hours - get the most work done at these times!

    Your question is a tricky one for me, having hugely deskilled in paediatrics over the last 8 years by virtue of where I work. My honest answer regarding Griff Jnr - I would do what I do with any similar kid I came across, and refer them to Rob Isaacs!

    I've been trying hard over recent years to delve into the literature and better understand the potential mechanisms of action of foot orthoses. Whilst there is plenty of research that foot orthoses can change the kinematics of gait is there not just as much which shows they often do not? Furthermore the angular changes have often been shown to be small, subject specific and unpredictable. However, I must confess to not knowing much about the literature in this field pertaining to children. Does it show anything different?
  8. Unfortunately, nearly all the kinematic orthosis research has been done on adults, while running. Little has been done on adults walking, and virtually none as been done on children walking or running. However, that does not mean foot orthoses don't change the kinematics of gait in children.

    I believe that properly-made custom foot orthoses do have the ability to alter the kinematics of children's gait from my gait observations and slow motion video of these children over the past 30 years with and without orthoses. However, to my knowledge, no formal gait studies have been done on flatfooted children with and without custom foot orthoses.

    Until that time, I still will be treating these children the way I would treat my own children and grandchildren. That is the way was taught to practice by my teachers (Drs. John Weed, Ron Valmassy, Mert Root and Rich Blake) and I feel very comfortable with that treatment philosophy, even though, I'm sure, other podiatrists might consider me "unethical" for treating children the way that these great podiatrists taught me to. ;)
  9. Rob Kidd

    Rob Kidd Well-Known Member

    With regards to the comment above from Kevin re: use of orthoses being unethical; I perhaps think that this is a pointed comment at MacDonald & Kidd: mechanical intervention in children, some ethical considerations. While memories are never accurate, and while we did make comment about this practice possibly being unethical, I seem to remember that we did not say that you should not treat. I seem to remember that we posed the question: are you sure that you should? While we took a load of flak at the time (including one infamous letter in JAPMA), various pod teachers in various countries have since said that this is a paper that they always draw to the attention of their little boys and girls, largely to make them think.
  10. Rob:

    Let me refresh your memory as to what the concluding paragraph was from your paper as to whether you suggested or not that using foot orthoses in asymptomatic children is ethical or unethical.

    No doubt about it, from reading the above, the late Drs. Mert Root and John Weed, Drs. Ron Valmassy and Richard Blake, Mark Russell, myself and thousands of other well-trained podiatrists in the United States may be acting and practicing in an unethical manner, according to these authors. All of the podiatrists mentioned above all prescribed and still currently prescribe custom foot orthoses for asymptomatic flatfooted children.

    Of course, maybe the authors of this article want to now retract their very strong moral admonitions against all of us who do prescribe custom foot orthoses for asymptomatic flatfooted children with significant gait pathology and/or a significant family history of painful flatfoot deformity?
  11. David Wedemeyer

    David Wedemeyer Well-Known Member

    Very important post Kevin. I am referred some non symptomatic pediatric flatfoot cases for corrective UCBL's to prevent future progression by both DPM's and MD ortho specialists. Apparently they see the rationale in getting ahead of the problem
  12. Craig Payne

    Craig Payne Moderator

    Sorry Kevin, I late getting back re the logical fallacy (I been busy; ......you know the 10 for 10 streak!). The logical fallacy of an 'appeal to analogy' does not mean the claim being made is right or wrong; its just that enough analogies have been shown to be wrong that to rely on them in an argument or debate means the use of any analogy in an argument is easy to dismiss.

    A simplified eg that we dealt with yesterday.
    1. Neck braces have been shown to weaken the muscles
    2. Foot orthotics are braces
    3. So therefore foot orthotics weaken muscles

    ...I sure you can see the logical fallacy there.
    (3) may or may not be true, but to argue it is based on the 'appeal to analogy' fallacy is a false argument.
    (and we know from other evidence that (3) is not true anyway)

    None of that means that analogy's are not useful to explain things; they just should not be used in debates (unless you want to have your argument dismissed as false!)
  13. If a PhD in biomechanics trained by Peter Cavanagh uses these analogies to explain how orthotics and shoes weaken feet in a television interview, then why can't a lowly DPM like me use them also? :rolleyes::confused::cool:

    I'm still not convinced that analogies can't be used effectively in debate to illustrate and support a point, Craig. However, for now, let's look at some of Irene's famous analogies she has been using the last few years.


    Last edited by a moderator: Sep 22, 2016
  14. Craig:

    I've done a little research and I have found that there is a quite a bit written on analogical arguments and analogical reasoning, which questions the validity of your contention that analogies "should not be used in debates (unless you want to have your argument dismissed as false!)".

    Therefore, your contention that my analogy of orthodontic braces are very similar in nature to custom foot orthoses is not necessarily "logical fallacy", as you call it, since no part of my analogical reasoning is false.

    Here is some further reading on analogical reasoning.



  15. Orthican

    Orthican Active Member

    I feel it might be worth noting for sake of the argument also that the use of dental bracing is temporary. 18 months or so. And even while temporary the effect of the bracing is noted after removal that the misalignments of the teeth are eliminated.

    Are we looking at the children's foot orthoses in the same manner? Can we say the same? To me I feel we cannot and would conclude that they are not analogous. Apples to oranges.
  16. Yeah, they can't be analogous since orthodontist treat teeth and podiatrists treat feet...absolutely no similarities there!!:bang::cool:
  17. Rob Kidd

    Rob Kidd Well-Known Member

    I do not wish to retract at all - and though I have not seen Mandy for some years (I am in Ireland currently, she is in NSW), I am sure that she would say the same. In your quotation, which I am entirely sure is correct, you may note phrases such as "May" be practicing unethically.

    One issue worries me here - not the use of orthoses in children. The issue that worries me is that of their justification upon the basis that all these senior people used them - that does not make their use or this practice right or justifiable. If you doubt me, get the history books out at the page entitled "Nuremburg".
  18. Hi Rob

    For anyone to justify intervention on that basis is fanciful; you treat according to what presents clinically and what you decide is the more appropriate Rx - not what you think someone else might do. I would hope no one would be stupid to explain their care plan in such a way, but you never know.

    As far as the ethics of treating a symptomatic flat foot I see no problem with good orthotic management. I have a weak right ankle after rupturing the anterior talofibular ligament when I was nine. Most of the time it's asymptomatic and I have no problem with it, but Sod's law applies occasionally and it's always the one that gets repeatedly strained. I have a laterally posted orthotic in my right badminton shoe and a lateral flange and posted insole on and in my walking boots. The rationale here is to try and prevent , as much as possible, the ankle flexion that subjects the remaining calc-fib ligament to the gut wrenching sprains I used to suffer regularly. It's a similar rationale I use when treating pes planus in children. I guess preventative practice is not de rigeur these days....maybe it's time to retire.

    Hope you're enjoying the black stuff.
  19. Rob:

    My biggest complaint about your paper is that you took such a lofty and judgmental attitude in your paper by claiming that regardless of the circumstances, a well-trained podiatrist that treats an asymptomatic child with flatfoot deformity with foot orthoses may, as a result, be unethical.

    If you had used the words "unwise", "against prevailing medical evidence" or "nonstandard" then I would have never had a problem with your paper. But, instead, you climbed up onto the top of the Tower of Judgement and proclaimed that podiatrists that treated their asymptomatic flatfooted children with orthoses, regardless of their family history of painful flatfoot deformity or abnormal gait function, may be unethical.

    To my knowledge, there has never been any other authors in the history of the podiatric medical literature who have felt they had the moral authority to publish a paper in a medical journal where they proclaimed that some members of their own profession may be unethical by using a treatment on a certain group of patients.

    Do you know of any? I don't.
  20. Nuremberg trials??? What does a trial of Nazi war criminals have to do with anything we are discussing here?

    Who should judge whether "this practice" ["this practice" = treating flatfooted children with custom foot orthoses that have parents with painful flatfoot deformity or that have gait pathologies due to their flatfoot deformity] is right or justifiable? Maybe that is the whole point.

    Certainly Mert Root and John Weed thought and Ron Valmassy, Mark Russell, myself and literally hundreds, if not thousands, of well-trained podiatrists in the United States think this practice of treating flatfooted children with custom foot orthoses that had parents that had painful flatfoot deformity or that had gait pathologies due to their flatfoot deformity is ethical.

    The issue that worries me here is that the justification for "this practice" being unethical is based on the opinions of two podiatrists who wrote a paper in an Australian podiatry journal (that is no longer in existence to my knowledge) from 16 years ago. Does this make "this practice" not right, not justifiable or unethical?

    What say you?
  21. Rob Kidd

    Rob Kidd Well-Known Member

    The point, Kevin, is this. At the Nuremberg trials, one of the recurring themes that emerged as a defence strategy, was something like "everyone does it, therefore it has got to be ok" - taken to the extreme, this argument could be used to say "it is alright to kill Jews - everyone does it", yet we all know that not to be the case. This habit became known as the "Nuremberg defence", hence my comment. You will find references to it in much ethics literature.

    More to the point, what I am saying is that just because your forefathers, academic mentors, heroes even, undertook a practice, does not make it right. And of course, before I am shouted down, it does not make it wrong either.

    When we wrote that paper, we were looking at evidenced based practice, a paradigm that does, or at least should, underpin modern medicine (or we can all blood let). At the time, though I am very out of date, there was no evidence that mechanical therapy prevented deformity, nor was there evidence that they did not cause future deformity. I do not retract, and I am sure Mandy does not either.

    You are correct that The Australian Podiatrist no longer exists, Neither does JAPA - but that does not retract from their value. The Australian magazine was superceded by JAFAR, JAPA was superceded by JAPMA, but then you knew that. Rob
  22. It's a paradigm we still work to, Rob, but it is not and should not be the sole principle clinicians should respect and adhere. If it were then we would never make advances or push boundaries. In the context of this discussion, even though there was lack of evidence at the time you published the paper - foot orthotic practice was very much in its infancy and we should be eternally grateful to those who were trying a different approach. Was it unethical to do so without published evidence to support it? I doubt it. It could equally be argued that it may be unethical not to treat asymptomatic flat feet with some orthotic therapy, given our knowledge today as I think a reasonable case could be made on 'prevention of injury' grounds.

    Best wishes
  23. Rob Kidd

    Rob Kidd Well-Known Member

    Good to hear from you Mark. I am currently in Galway, enjoying a Guinness or seven, talking at their school on Tuesday. I have not taught paeds since 1989 - bear that in mind for my next few comments. In the case you allude to above, the asympomatic flat foot, in student discussions re: treatment, the conversation would be something like this. Is this foot normal or abnormal? There is only really three answers to that: yes, no and don't know. That then led to the next part of the discussion - what action should we take? Again there are really only three possibilities: mechanical therapy of an appropriate type, nothing, or monitor. The two conversations sort-of meld together, and generally, we would agree that to monitor the asymptomatic flat foot was probably the best course of action. While I am way out of date, I am not convinced that anything has happened to change my mind. Rob
  24. It's so nice of you, Rob, to compare Mert Root, John Weed, Ron Valmassy, Mark Russell, and myself to Nazi War Criminals who murdered millions of Jews when we attempt to help children walk and run better, attempt to prevent their foot from flattening further and attempt to give them better lives when we prescribe them custom foot orthoses and follow them closely over their maturation into adulthood.

    Maybe when you get back up to date on the biomechanics of the foot and the mechanism of action of foot orthoses, your opinions will change. Until then, I will continue to act ethically with all my patients, including not withholding custom foot orthosis therapy from the flatfooted children who are asymptomatic who have gait pathology and/or a strong family history of painful flatfoot deformity, all because of some obscure article that was published 16 years ago in a now-extinct journal that proclaimed that practice was unethical.
  25. Jeez, steady, Kev. I'm up before the beak this Wednesday already - don't relish the prospect of getting shipped off to the Hague next!
  26. Rob Kidd

    Rob Kidd Well-Known Member

    Kevin, let us all slow down. All please note that in my original post the words "Nazi" and "trial" were not used by me. I did use the word "trial in my second post explaining the Nuremberg defence, but the word "Nazi", or the term "war criminals" has come from your pen alone.

    You miss the point, I am not criticising your colleagues at all. I am merely pointing out that because they do something does not make it right. I also took pains to point at that it did not mean they were wrong.

    Where this leads is directly to Helsinki and its declaration and subsequent revisions. This information provides a moral compass for medical practitioners and is constantly being updated. Having said that, no ethical issue is ever clear cut. You may well be right in your treatment. I am merely pointing out that one must not make the assumption that one is.

    The fact that the Australian Journal is now defunct and superceded is an irrelevance that you have now brought up twice. As they say in the the North of England (where I am originally from), you are knitting fog. Rob
  27. If you had made the above statement in your paper, then I wouldn't be bothering with all of his. However, let's again look at the last paragraph of your paper (McDonald M, Kidd R: Mechanical intervention in children: some ethical considerations. Australasian J Pod Med, 32(1):7-12, 2014).

    Did you say in your conclusion that "no ethical issue is ever clear cut"? I didn't see that anywhere within your paper.

    Did you say in your conclusion that "Podiatrists who do treat asymptomatic flatfooted children with foot orthoses may well be right in their treatment." I didn't see that anywhere within your paper.

    In my reading of your paper, it seems quite clear to me that you are very judgmental of those podiatrists who do practice as I do in treating asymptomatic flatfooted children with gait pathology and/or a strong family history of painful flatfoot pathology with foot orthoses. We are lumped in with the podiatrists who make custom foot orthoses for all flatfooted children, which I have never done.

    Maybe if you wrote that paper today, Rob, you would word things differently but in today's world, to me, it reads that any podiatrist that treats asymptomatic flatfooted children with foot orthoses in unethical. I believe many podiatrists will also read your paper that way.

    The problem now, as I see it, is that regardless of what you or I think now, there are many podiatrists in Australia and the UK (but nowhere that I know in the US) who think that the treatment of any asymptomatic flatfooted children with foot orthoses is unethical. As a case in point, read post #21 in this thread.

    Maybe if you could write a less judgmental and specific clarification of your original article, Rob, this would smooth things over with many of the US podiatrists who, when informed of the existence of your paper, are stunned and somewhat amazed that a podiatrist from another country would accuse another podiatrist of possibly being unethical just because they choose to treat asymptomatic flatfooted children with gait pathology and/or a strong family history of painful flatfoot pathology with foot orthoses. I feel that would go a long way toward helping explain your current opinions

    so that we can all work together to find ways to better the lives of our patients, and their foot health, whether they are children or adults.
  28. Rob Kidd

    Rob Kidd Well-Known Member

    You seem to be mixing what I said all those years ago in Macdonald and Kidd, and today's issues. To me the solution is clear. This should be submitted to a third party organisation such as a university or teaching hospital ethics committee for their comment and deliberation. I would like to make the assumption that you would stand by their decision making process. Their result should be published. I am happy to be second author on such a publication with you. Why do we not do exactly that?

  29. Rob:

    I appreciate the offer but think, considering my busy practice, lecture and writing schedule, I won't have sufficient time to take on such a project within the next six months.

    Just this last week, I wrote an article for Podiatry Today Magazine on this same subject we have been discussing in this thread where I mentioned your article (McDonald M, Kidd R: Mechanical intervention in children: some ethical considerations. Australasian J Pod Med, 32(1):7-12, 1998) and asked the question of whether treating asymptomatic flatfooted children should be considered "unethical". My short article will be published in the December 2014 issue of Podiatry Today.

    In addition, I am now writing my November 2014 Precision Intricast newsletter titled BIOMECHANICS OF FLATFOOT DEFORMITY – VOLUME IV" (the fourth newsletter in a four month series of newsletters) where I explain the mechanical interrelationship between subtalar joint axis medial deviation, decreased medial longitudinal arch height and decreased dorsal-to-plantar midtarsal joint thickness and its effect on foot mechanics and specifically on midtarsal joint dorsiflexion stiffness. These newsletters will be published in my fifth Precision Intricast book in approximately January 2019, assuming I am still alive and healthy in a little over four years from now.

    I have given much thought to, written many articles/newsletters on, and often have lectured nationally and internationally on the biomechanics of children and adult flatfoot deformity over the last three decades. In fact, during one of my lectures in the Townsville, North Queensland podiatry conference just a few weeks ago in your own country, I spoke briefly about whether treating asymptomatic flatfeet in children was ethical or not. Maybe someone who attended that lecture of mine can comment here on whether they agreed or disagreed with my opinions on this subject.

    Unfortunately, until we can get approval to do research on children in an ethical manner over long periods of time, we will all be guessing on how we can best help the feet and lower extremities of children and improve their lives by allowing them to grow into pain-free and active adults.

    Until that time that the research evidence becomes more clear, I will continue to treat symptomatic flatfooted children and asymptomatic flatfooted children with either a strong family history of painful flatfoot pathology or gait pathology with over-the-counter or custom foot orthoses and follow them closely during their years of growth into adulthood. In my opinion, this is the most medically ethical way of treating these children and ensuring that I can do everything, given my level of knowledge and three decades of clinical experience on the subject, to help them lead healthy and pain-free lives, from childhood into adulthood.

    STEVE LEVITZ Active Member

  31. I don't think that's entirely correct, Steve. I think it would be more accurate to say that foot orthoses have the potential to alter bony alignment permanently. It is well demonstrated that a combination of manipulation and serial splinting can correct the soft tissue contraction that is characteristic in TEV. Chinese foot binding can also realign joints and the skeletal structure of the food permanently. Clearly the majority of foot orthoses are designed to alleviate or modify the forces and stresses that cause injury to the foot and by definition - functional foot orthoses - shouldn't alter the underlying bony alignment. But I think there is a discussion to be had whether it is indeed possible and/or desirable to fit devices with such a radical prescription that it could alter bony alignment in the developing foot and whether it is possible to control the change in structure to an optimum position, for example - if such a thing exists.I don't doubt that foot orthoses have the potential to change structural alignment. For goodness sake, as a profession we've been spouting the mantra since time began that ill-fitting shoes have the potential to do exactly the same thing. If shoes can, why not orthotics? There's a big ethical difference between aesthetic body modification and functional modification. But it shouldn't preclude us from investigating the possibility.

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