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Custom made vs sham foot orthotics for achilles tendinopathy

Discussion in 'Biomechanics, Sports and Foot orthoses' started by NewsBot, Sep 22, 2014.

  1. NewsBot

    NewsBot The Admin that posts the news.


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    Effectiveness of customised foot orthoses for Achilles tendinopathy: a randomised controlled trial
    Shannon E Munteanu, Lisa A Scott, Daniel R Bonanno, Karl B Landorf, Tania Pizzari, Jill L Cook, Hylton B Menz
    Br J Sports Med doi:10.1136/bjsports-2014-093845
  2. Griff

    Griff Moderator


  3. Discuss:
    "although McCormick et al30 recently concluded that
    the sham foot orthoses manufactured from the same materials as
    in our study were a credible sham intervention (i.e. participants
    rated them as credible), their biomechanical analyses of these orthoses
    showed that they reduced plantar pressures at the heel, which
    suggests that they exert some mechanical effects. We did not
    conduct plantar pressure assessment (or any other biomechanical
    assessment such as kinematic analyses), so we cannot confirm this
    effect and influence in our participants. Nevertheless, the primary
    postulated effect of foot orthoses on Achilles tendinopathy relates
    to kinematic change and not redistribution of plantar pressures, so
    we doubt this would have had a significant effect."
  4. Craig Payne

    Craig Payne Moderator

    I would have thought kinematic changes would have no effect, If they work, it would have to be via kinetic changes.
  5. I would have thought that if one was to design an experiment on custom foot orthoses for Achilles tendinopathy that one would have used a custom foot orthosis with a heel lift added to the orthosis since this is the type of custom foot orthosis that nearly every good sports podiatrist that I know of uses in their orthoses for patients with Achilles tendinopathy. I believe Simon made this point even before the study was published.

    This would be the equivalent of trying to compare custom foot orthoses vs "sham orthoses" for the treatment of posterior tibial tendon dysfunction by using custom foot orthoses that are balanced with the heel vertical, are "semi-rigid" and without a medial heel skive versus using custom foot orthoses which are rigid, made with an inverted balancing position and a medial heel skive. Incorrectly prescribed custom foot orthoses are as useless as sham orthoses in these instances. I know, because every week of my practice for the past 20 years I have been converting other podiatrist's ineffective custom foot orthoses into effective custom foot orthoses by simple in-office modifications which I know will work for their specific pathology.

    It's really hard for me to get excited about custom foot orthosis research unless the custom foot orthoses used in these studies are the types of foot orthoses used by those who are most experienced and expert at foot orthosis therapy.:craig::bang:
  6. Agreed.

    What's more worrying is that the authors in their statement here don't appear to understand the fundamental principles of biomechanics nor the mechanics of foot orthoses. Foot orthoses work by altering the kinetics at the foot-orthosis interface. McCormick tested these so called "sham" devices and noted a kinetic influence at the foot-orthosis interface, viz. they are not "sham" devices; McCormick did not attempt to measure kinematic changes with these devices so we don't know whether or not a kinematic change occurs in concert with the kinetic changes observed with these devices. We do know that kinematics are driven by kinetics, plantar pressure measurement falls under kinetics, and we also have good reason to suspect that foot orthoses can exert a positive therapeutic effect by modifying the kinetics without an observable change in rearfoot kinematics. Seems to me the authors are frankly attempting to cast aside the previous research which demonstrates that their sham device is not a sham at all, in a wishful thinking/ head in the sand kind of way.:pigs: There is no such thing as a "sham" foot orthosis, and the sooner this is recognised the better. As for "Nevertheless, the primary postulated effect of foot orthoses on Achilles tendinopathy relates to kinematic change", who knows where this comes from as it is not referenced in the text. Primarily postulated by whom? Perhaps the authors primarily postulated this when they realised their "sham" orthoses had a demonstrable kinetic effect?

    Of course there should have been heel lifts on the foot orthoses. These comments were actually made before the trial was carried out, after the protocol was published. Why bother publishing the protocol if you are not going to act on your peers reviews of it? Rhetoric question.
  7. "Nevertheless, the primary postulated effect of foot orthoses on Achilles tendinopathy relates to kinematic change and not redistribution of plantar pressures, so
    we doubt this would have had a significant effect."

    Of course, Newton and Hook tell us that it is impossible not to have a kinematic change in response to a kinetic change such as a redistribution of plantar pressures at the foot-orthoses interface. Thus, accepting that McCormick observed change in plantar pressure distribution in response to the "sham" orthoses, this argument made above is actually fundamentally flawed/ nonscience.:morning:
  8. Yeah, but the problem with Isaac Newton and Robert Hooke was they were British and they despised each other!:D:drinks:rolleyes:
  9. My problem appears to be that I cannot spell Hooke. I know lots and lots of people who despise one another who are not English too, so it's not an English trait per se.;):drinks I think both Hooke and Newton were pretty good when it came to mechanics though; sorry they weren't from America, Kevin. But you got Thomas Edison who I don't think was overly fond of Nikola Tesla.
  10. "Americans" were still largely British subjects back in the time of Newton and Hooke. Newton and Hooke were both geniuses, lived and worked very close to each other but Newton had superior math skills that allowed him to prove the mathematics of gravitation with the calculus he invented in his 20's.

    The animosity between Newton and Hooke is just another example of two individuals not liking each other due to their competition within the scientific arena, which still happens frequently to this day.:drinks
  11. I'm just happy we don't see any of that kind of animosity here on Podiatry Arena.;)
  12. Athol Thomson

    Athol Thomson Active Member

    On a recent visit to Aspetar Bill Vincenzino said he did not think the sham orthoses from his RCT (on Anterior knee pain) were "sham" and feels they might have had some effect on the results.

    He used 3mm EVA insoles with a top cover made to look the same as the other vasyli OTC insoles used in the intervention group.


    The EVA moulded to the foot and shoe shape on follow ups and the subjects found them comfortable. In his opinion they were not "inert" so to speak.
  13. Thanks Athol. It's pretty obvious that you cannot insert anything into a shoe without changing one or more of the three fundamental modes of action of foot orthoses: surface topography at the foot-orthoses interface; frictional characteristics at the interface; load/ deformation characteristics at the interface. This is how foot orthoses "work". Anything placed in the shoe will modify these.
  14. Craig Payne

    Craig Payne Moderator

    Here is another 'placebo' orthotic study just registered:

    Foot Orthoses in Patellofemoral Pain Syndrome: a Prospective Randomized Study of Morpho-specific Versus Placebo Orthoses
  15. John 11:35 :bang:
  16. NewsBot

    NewsBot The Admin that posts the news.

  17. Wise words that fell on deaf ears four years before the study was published.:bang:
  18. I have read the authors response to the critique on their blog site. I've made my thoughts on this study known ever since the time when the protocol was published to more recently when the study itself was published. My main points of criticism during this time have not changed, so my criticism of it has certainly not been driven by the study outcome as the authors infer in their defence statement.

    I do not agree with their justification for a "sham" device when the "sham" device employed has known kinetic effects and we have good reason to conclude that foot orthoses work primarily by modifying kinetic variables. Their "sham" device reduced peak rearfoot pressure by 10%, by what percentage did their "active device" reduce peak rearfoot pressure? Unknown. In their paper they justified the use of the "sham" by saying it had an influence on pressure (a kinetic variable) but that they believed the primary "effect of foot orthoses on Achilles tendinopathy relates to kinematic change" so they "doubted" that the kinetic influence of their "sham" orthoses "should be of significant effect"; they doubted, but they really don't know for a whole host of reason's, not least because they don't know the role of peak pressure beneath the heel in the treatment of Achilles tendinopathy. Further, they do not report on the influences their "shame devices" had on kinematics, so this is an unknown also. What influence did their active devices have on kinematics? Unknown too. If the only testing the "sham" devices have undergone has been to investigate influences on peak pressure, we only know what their influences are on peak pressure; that doesn't mean they do not have any other kinetic nor kinematic influences, only that influence on peak pressure are all that has been reported to date. How do plantar pressure measurements correlate to kinematics?

    In their defence of the critique they justified their non-inclusion of a heel lift with a series of references which assessed the kinetic influences of heel lifts; none of the references they provided in their defence statement related to the kinematic influences of heel lifts, which is odd since they have clearly stated in their paper that they believe "the primary effect of foot orthoses on Achilles tendinopathy relates to kinematic change". What are the kinematic effects of heel lifts?
  19. Raphael1974

    Raphael1974 Member

    Thanks all for providing your Pod input on this. The authors are well respected in Tendon research internationally so this study (and the size of it) will have impact on what MSK Clinicians think.

    Is anyone able to formally reply to the BJSM with their own erudite take as I know MSK Clinicians (like myself) will be watching this and having a counter argument would be helpful since all we really have right now is the POV of the authors

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