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Community Biomechanics

Discussion in 'Biomechanics, Sports and Foot orthoses' started by sredpath, Feb 17, 2011.

  1. sredpath

    sredpath Member

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    Hello everyone this is my first post and Im hoping for some advice and evidence if possible.

    Im working for a trust at the moment which has a rather long biomechanics refferal list. My aim is to try and reduce that list by doing more in community clinics and freeing space in the biomech clinic for more complex cases.

    At present we are using we are using freelon insoles in the biomechanics clinic with felt. If a temp insole works we then send out for a custom othotic. This is costing a fortune to do and if the insole is not fitting correctly we are paying more on top to have it altered.
    At present we do not stock any biomechanics supplys in any other clinics.

    My idea was to to try and treat more in the community with simple pre fab devices. We wanted to start off by making a simple protocol to treat planter fasciatis. The first 2 items we were looking at ordering in bulk were slimfex plastic and slimflex simple 3/4 insoles as part of the treatment in the protocol. The protocol would also include the option of a case by case basis to order interpod orthotics.

    I have evidence to that supports the use of interpod othotics however I dont have anything to proove that the plastic and simples would also work. It would
    be appreaciated for any evidence contributions that would support the use of plastic or simples or if there is another type or pre fab that is cheap that would work better.

    The budget which we are looking at is less then £7.00 per orthotic. In addtion slimflex plastic would be used for other treatments in the future.

    All contributions welcome and all will be used to try and improove our biomechanics side of our service.
  2. RobinP

    RobinP Well-Known Member

    Can't provide you with a great amount of evidence about the orthtics I'm afraid. However, £7 per orthotic(single or pair?) isn't much to work with and i would suggest that green Slimflex with EVA wedge strips and some SCFare going to be the most likely winners at that cost.

    The only other thing I would say is that it might be worth going to someone with some statistics about (your example) plantar fasciitis. Point out that treated improperly, there can be an enormous amount of costs associated with plantar fasciitis in direct and indirect costs.


    Increased GP appointments
    Increase prescription medication
    Referral and appointment with orthopaedic surgeon
    Unnecessary and sometimes inappropriate corticosteroid injections
    Occasional surgical intervention required in the chronic patient which could have been dealt with earlier
    Unnecessary X rays and MRI scans

    ....the list goes on but you get my drift.

    £30 covers most OTC/modular orthoses that can quite adequately treat a multitude of conditions. They are also good enough to be used as definitive devices so negates the requirement for custom orthoses. Vasyli HD, interpod, TRIO(?) are all reasonable definitive devices that are worth more than £30 in my opinion.

    I understand that every department has budgets but service managers should be able to appreciate the logic.

    Good luck

  3. Paul_UK

    Paul_UK Active Member

    I work in a trust that does a lot of community biomechanics and we were using the Vectorthotics which I, and a lot of other people, found very good. They are easy to construct and change the prescription and also look quite professional which patients loved, I believe these were around £20, but am unable to be precise. Having said that we have just moved to Slimflex due to budget constraints.
  4. Hi,

    We have been using simple insoles for a long time and the main stay for this has been slimflex with wedging. You can get very creative with your prescriptions using this type of insole but you may wish to invest in some equipment to help with your manufacture i.e. heat guns, glue, Eva sheets, grinder etc!! In a lot of cases this is effective, so why do you need to move to a more permanent device? These are within your budget as long as they are for the majority. I pressure the £7 figure is based on an anticipated number of contacts?

    however, what has worked well for us is to have a 2nd level of device between the simple and before casted i.e. interpod, vector orthotics etc, which are outside of your £7 budget but are a good option for some pts that may not respond to simple insoles, but are a lot less than casted. Casted is reserved for the select few, and both the 2nd tier and casted options are reserved for the MSK specialist only.


  5. footfan

    footfan Active Member

    In 2009 South Gloucestershire PCT Podiatry department performed a cost comparison audit on orthoses. They compared the cost and therapeutic value of the use of prefabricated orthotic shells with the current method of manufacture using sheet materials in the manufacture of patients’ orthoses as well as efficacy and patient satisfaction of the orthoses prescribed. They did however have access to specialist manufacturing machinery and utilities, which was not included in cost calculation. The prefabricated devices (Group B) used in the study were restricted to the Mobilis X-Line insole, Algeos Slimflex and Slimflex plus and Algeos duomed full length insole. There has to date (December 2010) been no research into the effectiveness of these devices. The other intervention group received custom devices (Group A). The item costs included the cost of materials used, the salaried time of the podiatrist and the number of orthoses produced. In this study the custom devices for 29 patients required 21 laboratory hours whereas the 33 patients who received prefabricated FOs required only 1 hour of laboratory time resulting in a significant saving in salaried time. There was no difference in clinical time per patient between the two groups. The average unit cost per single orthotic manufactured from group A materials was £9.35 and from group B £5.14. This is an average cost difference of £4.21 per single insole (£8.42 per pair) with the prefabricated FOs the least expensive. This study was limited in that utility costs and manufacturing equipment were not included in costs; however it clearly indicated a direct saving via salaried time by utilising prefabricated orthoses. This study also determined patient outcome on Qualitative data and therefore assessment of performance is limited, and from my personal anecdotal experience of using these devices they offer little control and have a very short lifespan.
  6. sredpath

    sredpath Member

    Thank you for the posts people have put so far. In terms off equipment we do have a full orthotics lab of equipment. We have a grinder, over, vacuum seal device and some sort of saw to cut eva. However none of this is being used due to some health and safety reasons which are not very clear. The only piece of infomation I have so far why we cant use it is to do with the ventaltion and the glue used in orthotics i thought we could get around this with double sided tape if Im wrong please say.

    My second request is does anyone have any papers that proove gastroc stretching aids in the treatment of planter fasciaits. I know that it does the problem is I have no access to any journal database to reference from so any help papers would be appreciated.

    Thank you.
  7. sredpath

    sredpath Member

    Thank you this will really help is there ay reference or someway I can access this so I can include it in the write up I submit to the trust.
  8. davidh

    davidh Podiatry Arena Veteran

    Your Trust will have it's own, or access to A Postgraduate Library.

    Sort out access for yourself. They will be able to obtain Journals and Papers for you at no charge (maybe a minor charge to your Dept).

    PS This is one of the very few perks of working for the NHS:cool:.
  9. podtiger

    podtiger Active Member

    Have had some experience working in the NHS so I understand what you mean by slimflex.
    I actually found slimflex fairly ordinary in treating biomechanical problems. I would like to hear form anyone out there who found tha they actually worked for plantar fasciitis beyond a mild reduction in pain. Even with artful additions, wedging and 1st mpj cutaways they just didnt seem to help. The reason being i think was that they were too flexible. My department head used to love them because they were so cheap. To our detriment though we found them ineffective.
    The times I would use a slimflex would be as a base for redistributive padding additions. In the case of 1st mpj pain/ hk/ulcer.

    I would prefer interpods or vasyli orthoses for but again you may be hamstrung by the cost.Maybe the NHS could consider charging a cost for these orthoses to patients to help maintain a quality.Pigs might also fly.

    Just another criticism of the NHS(if i may?). I found a lot of the staff used to revert to these "freelings?" almost as a default mechanism. Sound biomechanical assessment was often ignored in pursuit of a quick fix. Worse still you would also see these so called Podiatry consultants coming in wielding a cortisone needle before any substantial assessment and cause analysis was actually conducted.

    Biomechanics is not a specialty. Its the base on which podiatry is built. You may be better served to get your manager to upskill your staff into the basics of biomechanics.
    Sorry for banging on there.
    Good luck with your career Sredpath.
  10. footfan

    footfan Active Member

    OK just a few things

    -Slimflex are like BASIC CHICKEN FROM ASDA, cheap and nasty but if its all you afford its better than none. There is no research to my knowledge on Slimflex and its applications. Plantar Faciitis is self limiting meaning in the majority of cases the infamous 3mm sterofoam sham device used in previous studies would work !!!! =S.
    So yes stretching and Slimflex will magically solve 70% of cases.

    - Interpod are expensive but there is research to back there claims a la Craig Payne and Co.

    - People disrepute Salfordinsoles but the fact of the matter is professor Nester and his crew have pretty much backed up most claims including lateral forefoot wedgeing, they also come with a lifetime guarantee and can be put in your washing machine !! Who else offer that??

    For a good overview of Prefabs look at Karl Landorf's Systematic reviews- theyre free via google scholar =D, I have great respect for Karl and his team.

    Interpods can be bougt from Algeos at a discount in bulk ive discussed this with James there account manager and hes very helpful- free bit of advertising for craigs insoles =)

    I could bang on but wont for those that want any references just ask .

    For all you people that love SLIMFLEX http://www.apcrc.nhs.uk/Service_Evaluation/Feature-orthoses-an-audit.pdf

  11. podtiger

    podtiger Active Member

    Might have to agree to disagree on the use of slimflex.
    I think in life you get what you pay for and unfortunately for the most part slimflex is a poor product. I'm 70% sure of that.
    What other prefab can you roll up into a ball?
    How is this meant to facilitate adequate foot function. I know it is just a base but come on.
  12. RobinP

    RobinP Well-Known Member

    I can make an effective device out of SCF and you can roll that into a ball. Granted it is not a prefab but it is equally cheap.

    It is wrong to say that Slimflex are poor products. If the device is offering sufficient reduction in force in the damaged tissue to bring them to within its zone of optimal stress, it is a great product. For many people, the kinetic shift brought about by a slimflex is enough.

    That being said, I wouldn't be putting a Slimflex on someone with tib post tendinopathy as generally the reduction in residual pronation moments is unlikely to be enough.

    I don't use slimflex insoles and I think the practice of sticking a green slimflex in someone's shoe if they have plantar fasciitis is wrong. I understand the need for treatment protocols for GPs etc but pigeon holing a condition for a pre determined course of treatment is foolish in my opinion.

    I can't really even remember how this thread started but I had better dismount this rather large equine creature.

  13. footfan

    footfan Active Member

    I actually AGREE with all these statements Podtiger =D.

    Robin is right though we cant say it doesnt work in certain instances. I just think for £16 (What our clinic charges for slimflex) the longevity and piss poor performance is inadequate compared to our SalfordInsoles that have 2 densitys , are research backed and a life time guarantee for £30 .

    Regards FF
  14. RobinP

    RobinP Well-Known Member

    Fair point
  15. Griff

    Griff Moderator

    Jon, as a 3rd year student at Salford your loyalty is commendable. However out in the clinical world I must tell you that Salford insoles are not generally as well regarded as you might think/hope. And to say they are 'research backed' is a rather grandiose term for what literature is currently available.

    I pretty much agree with every word in Robins post (#12)
  16. footfan

    footfan Active Member

    Lol who said i was a student?? i dont think saying "research backed" is exagerated because there is research to demonstrate thier effectiveness. when i did my origional review on prefabricated orthoses and cost audit it showed that algeos slimflex had no research to date on thier effectiveness or longevity and i only used salfordinsoles as an example to compare relative cost, i could have used interpod i suppose.
  17. Griff

    Griff Moderator

    You did Jon. If you were a 2nd year at Salford in March 2010 then by my calculations you are a 3rd year in Feb 2011. Am I incorrect?

    Research demonstrating their effectiveness of what?
  18. footfan

    footfan Active Member

    Looks guys i used that particular insole as an example becuase it had some research conducted within a UK Univeristy and has a lifetime guarantee, i never said it was peer reviewed,Michael I couldnt find anything that demonstarted the effectiveness of Algeos Slimflex .

    What prefabricated devices would you recommend to the thread starter? It seems they have a very low budget, I suggested prefabs because salaried time soon mounts up when making the basic devices yourself.
  19. But Jon I don´t beleive anyone has said Algeos Slimflex is


    My option a technician , and casted devices will probably save time and money over a 5- 6 year period.

    But I was asking about the research not giving any advice re NHS.
  20. footfan

    footfan Active Member

    Hi Michael,

    Ive reviewed your posting and yes the research seems very subjective and anecdotal. It does now lead to me to question why there standard insole was not peer reviewed, when the research has been conducted?

    Ill ask the creator on Tuesday when i see him.


  21. fishpod

    fishpod Well-Known Member

    try tred lite orthotics from rsl steeper about 15 quid per pair not far off your 7 quid per orthotic had a delivery of salford insoles who said they wewre excellent for footballers gave 3 pairs to premiership players i cannot print thier replies iwould be struck off sent all samples back even the free ones. see i am ethical the players loved schien football insoles. the tred lites are perfect for nhs patients cheap vfm but very effective and durable hope this helps .
  22. JB1973

    JB1973 Active Member

    i think its to do with expectations. Slimflex do what i want them to do for the patients that i give them to (with and without additions). i have no research or audit to back this up but its somemething -given the time- i would like to try. Problem is, you rarely give an insole without any other intervention. Salford insoles i havent tried but like Ian said, what i have read doesnt make me want to try them in a hurry. I like vectorthotics but they are expensive (in NHS terms). I recently stared using slimflex simple and kinetic but too early to say if they have been succesfull. Xlines are good as well in my experience.
  23. footfan

    footfan Active Member


    Ok enlighten me what have you read about Salford Insoles?

  24. RobinP

    RobinP Well-Known Member

    I can't speak for JB but I've read this much and I'm not likely to be rushing out to buy them. Of course, this is just people's opinions and not really up to much scrutiny.......much like the Salford " research" paper

  25. footfan

    footfan Active Member

    Hi all,

    As promised Ive spoken to the Inventor of Salford Insoles and he says the research IS CURRENTLY BEING PUBLISHED, he wouldnt tell me which journal though, he says one of the research teams PhD project regarding the Lateral Wedge is published so theres some peer review for you guys on that front although the lateral wedge devices are alot more expensive.

    Also he has told me they have gone beyond usual assesment of joint movement within the foot and placed pins through the bone to assess the effect of Salford Insoles, something nobody else has done apparenty.

    Paper on Pin inserted into bone and affects of Salford insole


    Published paper on Salford Lateral wedges http://www.seek.salford.ac.uk/viewPublicationDetailsAction.do?publicationNum=27749
  26. davidh

    davidh Podiatry Arena Veteran

  27. Jon it´s a bone pin study done at Karolinska Institutet in Stockholm. There was no insoles used in that study. While these studies are some of the most interesting Ive read, it got nothing to do with an insole Salford or otherwise.

  28. Ian Linane

    Ian Linane Well-Known Member

    I tend to use whatever is most suited to the need at the time and range from mainly custom to slimflex and have even used a sheet of A4 with felt on it.

    Slimflex work for me, as a temp, mainly because I find the heel cup great for mocking up a lateral or medial skive effect, they also seem tolerable to most pts. They are rarely used on their own and tend to be an adjunct either to soft tissue and joint mobs (for various conditions). I think its what you do with them.
  29. fishpod

    fishpod Well-Known Member

    is not phil laxton the inventor of the salford insole they seem to me to be arock hard full length anti pronatory otc insole in a cheap box made of cheap plastic and its bloody impossible to get anything to adhere to them if you want to adapt them. Not exactly reinventing the wheel. cost 30 quid not worth afiver imho if they were 5 quid i would still not use em.I have seen superior products on the shelves at walmart for under 20 bucks .
  30. footfan

    footfan Active Member

    Think we got our wires crossed, the pin study with the insoles is currently being published. The reason it was conducted in Sweden is to do with ethics approval the pins were not allowed to be inserted by anyone other than a orthopaedic surgeon with special approval which could not be granted within the UK.
  31. Jon you do think your in the know don't you...... a bit special

    The above information is not new again we come back to what you said

    Which it is not. So no wires crossed here.

    When the next paper is published by the foot and ankle research team most people will look at the angle of wedges used, rather than if they used a Salford insole. You may use it to think the device is the best but as it has not be compaired to anything else we will not know.

    I for one can't wait to read the paper, probably not for the same reason as you.
  32. podtiger

    podtiger Active Member

    I guess if we all had the attitude of if it kind of works and it's cheap then it must be ok then podiatry would not have progressed out of the dark ages.
    I think we need to be better than this. Our peers and the peers that follow us deserve better. Shoestring budgets notwithstanding, last time I checked England is not a third world country. It's time we gave the public a quality service and that includes quality products.
    If it means making the public pay for appliances then so be it(that includes the great NHS). I can hear the sighs in our beautiful country now. I'm sure most people could afford to pay extra for something that will probably last longer and is probably much better. Our mismanaged podiatry departments have been running on a false economy for way too long.

    The use of slimflex is just 1 symptom of a wider malaise. And no I'm not a 3rd year student either. Time for a Tesco ready meal I think.
  33. davidh

    davidh Podiatry Arena Veteran

    I think this is absolutely right.

    But not the bit about a Tesco oven-ready meal - do you have any conception of the junk in those things:eek:.
  34. fishpod

    fishpod Well-Known Member

    well said podtiger of course nhs patients should pay for reasonable quality orthotics. due to poor budgets some of the rubbish thay come out with is adisgrace one of my local trusts gave apatient 3mm poron base with a met bar half stuck down.It looked like a 3 yr old had made it the guy took a day off work to attend the lab he would have done better at the poundshop. ifpatients need things like vasyli talarmade etc why not charge them 25 quid they can afford it and are willing to pay they have nhs dentistry and still pay for stuff.
  35. footfan

    footfan Active Member

    Also this would differenciate the people who really want help or are in pain because they will be more willing to pay (although i wouldnt want to charge people personally). I think a cochrane review on orthoses especially prefabs might be good because the NHS could think about producing thier own device across all services, say for plantar faciitis this would bring the cost per unit right down rather than like 1 trust i know using slimflex and paying an outside lab( again no names) to attach medial and lateral wedges at £20 per time :eek:
  36. footfan

    footfan Active Member

    Oh yeah michael, well my dads bigger than your dad!!! :rolleyes: seriously i got the wrong paper in a link , also i meant i miscommunicated the information. And im far from special its just the people i speak to on a daily basis ARE SPECIAL and i try to absorb and diffuse the grape vine knowledge for anyone who cares and those that dont can just ignore me i wont take offense and you dont have to comment but it is fun :boxing:

    Your right about the results from the next study but it will be peer reviewed and the devices will have SOME scientific basis for use , as much of what we use doesnt (I mean devices , not practice e.g. actifit insoles)

    For the next PERSONAL attack on me , please see

    Let him who is without sin cast the first stone

    Read more: http://www.answers.com/topic/let-him-who-is-without-sin-cast-the-first-stone#ixzz1FXe1QwWp

    Go and offer a point of view no more ;)
  37. Jon a Bible quote how funny I won´t go there.

    I will give you some free advice take it or leave it ...

    Everything some tells with regards to Podiatry treatments insoles, biomechanical theory like we discuss on here - ask yourself is it true, don´t believe is, investigate you might find in to be correct you may think otherwise.

    Just because your close to folks a Salford doesn´t mean the insole is good, doesn´t mean it is bad but you need to look at things with a critical eye.

    If the next bone pin study that is my understanding that Chris Nester is the lead author on that looked at wedges and used bone pin analysis to detect difference in kinematics shows in-fact that the kinematics did change it will not mean Salford insole are better than any other, what it will show is that foot kinematics changes with the use of a certain degrees of wedges.

    To say say that the insole is evidence peer review backed is maybe true in the future but it is stretching the truth what more importantly it will show that an insole any insole with x,y and z wedge angles could have the following kinematic affects, Salford being one of them.

    I look forward to reading the paper to see if the solved one rather large problem with the methodology of the experimental design .
  38. footfan

    footfan Active Member

    You can keep the condescension
  39. Peter

    Peter Well-Known Member

    I had some salfordinsoles sent to me (always worry when they send you a BIG box full!)

    After looking at them, realising they weren't that customisable, I phoned them to ask if they wanted them back. They weren't that bothered.

    Still got a big box full in the workshop now!

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