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Does Everyone need Insoles?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Robertisaacs, Jul 25, 2011.

  1. Members do not see these Ads. Sign Up.
    This thread has been rattling around in my hindbrain for a while. Two things have pulled the trigger to make it solid.

    One was that I have the misfortune to be reviewing a paper recently published by our own dear Brian Rothbart. The usual dangerous mix of what looks like science but is actually a thinly veiled infomercial, and before and after pictures. It includes the claim that if the forefoot is not plantargrade in neutral static stance, this must be due to talar torsion and as such requires treatment.

    Garbalosa, from memory, found an average forefoot inversion angle of 8 degrees. So that would be everyone then.

    Foot typing systems often raise this question as well. One does not generally see a "healthy" foot type in the selection. It is presumed that an insole is required and the question is only, which type.

    Finally, we have the good old "overpronation" correction. Often based on nothing more sophisticated than a static RSCP. I'm indebted to Simon for posting this study


    Which shows a Mean RSCP of 7 degrees everted in a healthy population. So thats insoles for everyone there then.

    So here is the question. Are such models as suggest that everyone / most people require orthoses for "correction" (as opposed to pathology) anything more than cynical attempts to cash in on people's credulity to make a few quid? Or are they actually based in anything approximating to science.

    I note in passing that the three models I described are highly diverse and unified only in that they teach that pretty much everyone needs insoles.
    Last edited by a moderator: Jul 25, 2011
  2. Be careful of your interpretation of the statistics, Robert. Just because the population mean is above a clinical threshold, it does not infer that everyone within the population is above that threshold. Understand?
  3. CraigT

    CraigT Well-Known Member

    No-one needs orthoses. They just will have different levels of benefit from them...
  4. Crystal.

    I'll have to dig it out but from memory the number was 81% had FFvarus of 5 degrees or more. So not all. But most. My bad.
  5. Griff

    Griff Moderator

  6. 86.67% then. I was close.
  7. Rob Kidd

    Rob Kidd Well-Known Member

    The concept of everyone needing insoles (ie mechanical interference) is not biologically plausible; it would have done the whole Root model a load of good to go back to proper biology (and please do not forget, medicine is simply a branch of applied biology) before it produced some of its more ludicrous suggestions. I remember reading, but now forget where, that all of us needed orthotics.... Evidence first please, gentle persons. Rob
  8. RobinP

    RobinP Well-Known Member

    Ah......if only
  9. W J Liggins

    W J Liggins Well-Known Member

    Raises interesting questions though. I work (largely) on the basis of symptomatology. So an individual with a RCSP of 7 degrees inverted is symptomatic. All other things being equal, should an individual with no symptoms who displays the same presentation not be treated on the basis that it is demonstrable that they might display the symptoms as time goes on?

    All the best

  10. P = G + E + (G x E)

    P= phenotype (or pathology in this example)
    G= genotype
    E= environment

  11. Only if the rscp is the only element in the equation. And all other things will never be equal. Even if every other biometric element is the same, the environment will not be. The person with the symptoms could have picked up an injury entirely independently of the biometric presentation. Through trauma by example. In which case the fact that they have an RSCP of 7 degrees inverted or everted might be no more relevant than their hair colour.
  12. davidh

    davidh Podiatry Arena Veteran

    Nice question Rob.

    I'll trot out my piece, then retire gracefully.

    To boil the question down, we are talking about 80% or so of the population, by inference of data contained in a few studies, having the rearfoot (RF) or forefoot (FF) inverted relative to the supporting surface. The magnitude of inversion is probably important, the actual quantification (is it 7 degrees or 8 degrees) less so, because diurnal variation means that joint movement, which affects compensatory changes which may or may not be responsible for producing symptoms, will be different depending on the time of day.

    The supporting surface is the key. When it is hard and flat, as it is for most of us for most of the time in the West, the inversion (and corresponding compensation) becomes obvious. When the ground is undulating and soft in places the inversion and compensatory changes become less obvious.

    We were never designed to stand or ambulate on hard, flat surfaces, and it is nonsense to suggest or even suppose that we have evolved for doing so. Therefore the proposition that we all have RF or FF inverted relative to a hard flat surface would seem to me to be perfectly reasonable. Indeed a foot which is slightly inverted is in an ideal position to come up onto the forefoot for rapid propulsion as and when needed - think being in the wild either chasing or being chased.

    I offer this question for interest and as something to consider. Please note that I'm not suggesting it as proof of anything.
    Has anyone on the forum ever seen Roots criteria of normalcy anywhere but in an anatomical model of the foot?

    Do we all need orthotics? No.
    However, most of us will find some kind of support (usually a shoe with a small heel suffices) more comfortable than bare feet when standing or walking on hard flat surfaces for any length of time.

    As ageing, overuse (and sport), and/or degenerative disease cut in and produce symptomology of one sort or another some of us may find orthoses helpful.
    Last edited: Jul 26, 2011
  13. W J Liggins

    W J Liggins Well-Known Member

    RI quote

    Only if the rscp is the only element in the equation. And all other things will never be equal. Even if every other biometric element is the same, the environment will not be. The person with the symptoms could have picked up an injury entirely independently of the biometric presentation. Through trauma by example. In which case the fact that they have an RSCP of 7 degrees inverted or everted might be no more relevant than their hair colour.
    Has anyone on the forum ever seen Roots criteria of normalcy anywhere but in an anatomical model of the foot?

    DH quote

    Do we all need orthotics? No.
    However, most of us will find some kind of support (usually a shoe with a small heel suffices) more comfortable than bare feet when standing or walking on hard flat surfaces for any length of time.

    As ageing, overuse (and sport), and/or degenerative disease cut in and produce symptomology of one sort or another some of us may find orthoses helpful.


    Precisely - so treat according to presenting complaint (exceptions proving rules).

    Bill Liggins
  14. Yep. Thats Tissue stress. :drinks
  15. blinda

    blinda MVP


    Ya pipped me to the post. My thoughts exactly.
  16. efuller

    efuller MVP

    If you could show that your measurement was reliable and if people with that measurement could be shown to be to be reasonably certain to develop a pathology prevented by orthotics and treatment with orthotics did not cause worse problems, then you could treat the mesurement. Think high blood pressure as a model. No symptoms, but predictive of pathology.

    This doesn't get past the first "if" If you measurment to treat needs to be accurate within 2 degrees (heel is more than everted 5-7 degrees) and the measuremnt error is +/- 5 degrees then you can't accurately determine the rest of the conditions for treatment.

    Now, if we could put a number to STJ axis deviation, we might be able to predict certain types of pathology.

  17. CraigT

    CraigT Well-Known Member

    It is an interesting question.

    I work in a Hospital where the majority of my patients do not pay for their treatment. I am also expected to provide the highest level of care and the material costs are really not an issue.
    We also see quite a few athletes who do not have specific symptoms- ie I see them as part of an overall screening.

    When I am considering foot orthoses for these individuals I of course look at a range of biomechanical factors... (although FF to RF relationship would not be one if it was a quick screening).
    One thing which I think is important is a history. Often patients will have warning signs that they are at risk of an overuse injury- they may have had shin soreness in the past, or complain of low grade MLA pain when fatigued.
    You also have to get an idea of loading levels and their aims. What may not be significant to a sedentary person can become very significant to an athlete. I have had athletes that have been running 120km a week, but get injured if they do more- a biomechanical intervention then allowed them to push to 160km a week.

    So... if I see concerns in my assessment- medially deviated STJ axis, increased 1st MTPJ stiffness, end ROM pronated, increased supination resistance etc... and they have a history of problems which may be related... I would look at orthoses for them despite them being essentially asymptomatic.

    Compliance is another matter.
  18. Eric makes a good point here. What are needed are predicitve models such that we can assign risk.

    We developed A method of quantifying transverse plane stj axial position about a decade ago for an undergrad project.
  19. CraigT

    CraigT Well-Known Member

    Please share!!!
  20. We palpated the axis then used an instrument we built which was basically a sheet of clearPerspex folded at a right angle to form a heel seat. The main face under the plantar foot had a fine grid printed on it which enabled us to set up a x, y coordinate system. We recorded where the projection intersected the x and y axes and used trig to work out angular deviation. You could probable use a flat bed scanner and a basic piece of software to do it these days.
  21. CraigT

    CraigT Well-Known Member

    So mark the foot a la the original article from Kevin?
  22. Yep. We did reliability trials intratester was fair ICC 0.78; inter poor ICC 0.66
  23. efuller

    efuller MVP

    What would be important is ranking of most medially deviated to least across testers. If that could be established as reliable then the absolute number would not be as important once and individual tester had established average values.

  24. Tylermcc

    Tylermcc Member

    Interesting thoughts...., can you provide more on your study Simon?

    "We developed A method of quantifying transverse plane stj axial position about a decade ago for an undergrad project."
  25. RobinP

    RobinP Well-Known Member

    Yes. This Quadrastep System has an orthotic for the "neutral" foot!

    Actually, what I find quite interesting is that, despite being a foot typing system, it partially follows a tissue stress model in that a neutral foot is every bit as capable of being pathological and symptomatic than a "severe pes planovalgus" type. This is probably where the correlation ends, however.
  26. Rob Kidd

    Rob Kidd Well-Known Member

    Simon's simple but effective equation - P = G + E + (G x E) is really only a re-statement of Waddington's famous work from the 50's, in which he proposed an epigenetic landscape, essentially suggesting that we are a product of both our genetics and are environment. HOWEVER - he went further. More than implicit in his work is the principle of genetic assimilation - that is the crossing of Weisman's barrier and genetic assimilation. Put another way, diploid to haploid transition. If correct, and I undersstand that though a mechanism is not as yet forthcoming, it is accepted as a very basis of evoution, this has profound implications for pathology. Come back H P Du Gillet (sp?) and the atavistic theory of Hallus Valgus - all is forgiven!
  27. docbourke

    docbourke Active Member

    I am astounded at the concept suggested that everybody needs orthotics when there are in fact very few if any conditions that have been scientifically proven to be cured by orthotics in well conducted prospective randomised controlled trials and definitely no evidence that orthotics will prevent any pathological states in a general population, especially an asymptomatic one. Arguments about sub talar angles, hind and mid foot supination/ pronation are ridiculous without massive population studies to determine normal values at all ages and in all races and sexes. We do not even have standardised terminology let alone standard measurement techniques. Are we comparing apples to pears ? We don't know whether these values change from day to day or with activity or age. In the real worls we must identify pathology and treat it, not devise so called treatment modalities for conditions that don't exist or are just part of the normal population variance.
    We treat patients not goniometer measurements. To suggest that the vast majority of pathology is due to a particular biomechanical variant is naive and narrow minded. We must provide evidence from well conducted research to prove our teatments are both necessary and effective rather than suggesting our interventions are going to enhance an otherwise asymptomatic patient population.
  28. efuller

    efuller MVP

    What's up doc,

    There has been a trend toward sarcasm on the arena of late, and you might look at the suggestions that everyone needs orthotics in that light.

    I wouldn't call discussion of subtalar angles ridiculous. There is a quite plausible explanation of how variation of the projection of the STJ axis into the transverse plane may be relevant to the prediction of pathology. See my paper on Center of Pressure and its theoretical applications to the prediction of pathology.

    Fuller, E.A. Center of pressure and its theoretical relationship to foot pathology.
    J Am Podiatr Med Assoc. 1999 Jun;89(6):278-91.

    There are studies that show that there is variation in the population and there would be no need to do further studies also including race and sex as this is a mechanical effect that would not be affected by those variables.

    True, there are no published studies on reliability of the measurement, but this is an excellent area for further research.

    Doc, how would you prefer to be addressed? Welcome to the arena.

  29. We should have got that study published- my bad. It was on the agenda and never got around to it. Don't even know where the student who carried it out is now. Kate Claydon- where art thou? Still have a copy of the dissertation.

    Yeah, Doc, what are you a Doc of?
  30. from profile.

  31. Thanks Mike.
  32. DocBourke:

    Did anyone say, in this thread, that "everybody needs orthotics?" You may want to read the initial posting much more closely.

    As far as clinicial practice habits are concerned, since when have orthopedic surgeons needed "massive population studies" to justify doing new, un-researched and untested invasive procedures which, if they fail, may cause the patient more pain and disability than if they were to simply not treat the patient?

    I have worked in an orthopedic practice, with orthopedic surgeons, for the past 26 years and am very familiar with the way that orthopedic surgeons practice. Certainly I have never seen the orthopedic surgeons I work with wait to perform surgical treatments only that have been validated by "well conducted prospective randomised controlled trials". Rather, they tend to do the surgeries that they have been taught by their professors in their orthopedic residencies or have read in books or have heard about in seminars.

    Do you only perform treatments now that have been extensively studied by "well conducted prospective randomised controlled trials"? Here in the States, both orthopedic surgeons and podiatrists tend to perform the treatments that tend to work the best for their patients and enjoy reading the literature when the good studies do come out to either support or refute their clinical observations...is this different in Australia?
  33. CraigT

    CraigT Well-Known Member

    Hi DocBourke
    It is refreshing to find an Orthopod who has taken the time to read and comment on Podiatry Arena! Welcome!
    I think you will find that this in this thread most posters are being quite facetious when they are suggesting that 'everyone needs orthotics'... Robert, I blame you :hammer: :D
    I would like to pick up on a couple of comments though...
    Perhaps... but you are talking in very definite terms. I would suggest to you for starters that orthoses are generally only part of a overall treatment protocol. Also, orthoses don't 'cure'- they change forces and load. This should give the body a better chance to heal itself if the pathology is not too great. Does that not make some sense?

    While we are interested in evaluating things like the subtalar joint axis position and pronation/ supination moments, I suspect this is somewhat different to what you are thinking when you hear
    I would recommend looking at the paper Dr Eric Fuller mentioned earlier as a pretty good example to show that also 'we treat patients not goniometer measurements'.
    Geez... I don't even own a goniometer...

    I genuinely hope you stick around and contribute to our forum:drinks
  34. Gerard, welcome.
    You can't beat measuring angles from x-rays in a bit of pre-operative planning. Funny how post-operativley they seem to loose their significance. :rolleyes: I got a tractograph- it makes a great bookmark.
  35. See also this recent paper from a group of researchers in Germany:

    Spatial orientation of the subtalar joint axis is different in subjects with and without Achilles tendon disorders.

    Or this article from nearly two decades ago that showed a correlation between knee joint loads during seated cycling and subtalar joint axis spatial location:

    The effect of lower-limb anatomy on knee loads during seated cycling.

    Or this article from eight years ago that shows a correlation between supination resistance and subtalar joint axis location:

    Position of the subtalar joint axis and resistance of the rearfoot to supination.

    And explained very nicely in an orthopedic journal by my co-researcher Steve Piazza, PhD:

    Mechanics of the subtalar joint and its function during walking.
  36. docbourke

    docbourke Active Member

    Orthopaedic foot and ankle surgeon. Maybe not as well read as should be. Time limitations with teenage children and my own selfish sporting pastimes. In surgery I note a great variation in sub talar morphology. Maybe subtaler angle is not as constant and measurable as we think. If so can we really describe normal let alone abnormal mechanics in a world with less than perfect measurement devices and techniques.
  37. DocBourke:

    It is because of this great variation in subtalar joint morphology and, in addition, the great variation of the spatial location of the subtalar joint axis relative to the weightbearing structures of the rearfoot and forefoot that we can quite coherently explain the mechanical etiology and mechanical treatments of many pathologies of the foot and lower extremity within the bipedal human.

    I would be happy to provide you with all of the papers and books where I have discussed the biomechanical importance of subtalar joint axis spatial location if you could provide me with your private e-mail.:drinks


    Kirby KA: Foot and Lower Extremity Biomechanics: A Ten Year Collection of Precision Intricast Newsletters. Precision Intricast, Inc., Payson, Arizona, 1997.

    Kirby KA: Foot and Lower Extremity Biomechanics II: Precision Intricast Newsletters, 1997-2002. Precision Intricast, Inc., Payson, Arizona, 2002.

    Kirby KA: Foot and Lower Extremity Biomechanics III: Precision Intricast Newsletters, 2002-2008. Precision Intricast, Inc., Payson, AZ, 2009.

    Kirby, Kevin A.: "Methods for Determination of Positional Variations in the Subtalar Joint Axis", Journal of the American Podiatric Medical Association, 77: 228-234, May 1987.

    Kirby, Kevin A., Alan J. Loendorf, and Renee Gregorio: "Anterior Axial Projection of the Foot", Journal of the American Podiatric Medical Association, 78: 159-170, April 1988.

    Kirby, Kevin A.: "Rotational Equilibrium Across the Subtalar Joint Axis", Journal of the American Podiatric Medical Association, 79: 1-14, January 1989.

    Kirby, Kevin A., and Donald R. Green: "Evaluation and Nonoperative Management of Pes Valgus", pp. 295-327, in DeValentine, S.(ed), Foot and Ankle Disorders in Children. Churchill-Livingstone, New York, 1992.

    Kirby, Kevin A.: "The Medial Heel Skive Technique: Improving Pronation Control in Foot Orthoses", Journal of the American Podiatric Medical Association, 82: 177-188, April 1992.

    Ruby, Patricia, Maury L. Hull, Kevin A. Kirby, and David W. Jenkins: "The Effect of Lower-Limb Anatomy on Knee Loads During Seated Cycling", Journal of Biomechanics, 25 (10): 1195-1207, October 1992.

    Kirby, Kevin A.: “Biomechanics and the Treatment of Flexible Flatfoot Deformity in Children”, PBG Focus, J. Podiatric Biomechanics Group, 7:10-11, June 1999.

    Kirby, Kevin A.: “Biomechanics of the Normal and Abnormal Foot”, Journal of the American Podiatric Medical Association, 90:30-34, January 2000.

    Kirby, Kevin A: “Conservative Treatment of Posterior Tibial Dysfunction”, Podiatry Management, Vol 19, No 7, pp. 73-82, September 2000.

    Kirby, Kevin A: “Subtalar Joint Axis Location and Rotational Equilibrium Theory of Foot Function”, Journal of the American Podiatric Medical Association, 91:465-488, October 2001.

    Lewis GS, Kirby KA, Piazza SJ: A motion-based method for location of the subtalar joint axis assessed in cadaver specimens. Presented at 10th Anniversary Meeting of Gait and Clinical Movement Analysis Society in Portland, Oregon. April 7, 2005.

    Roukis TS, Kirby KA: A simple intraoperative technique to accurately align the rearfoot complex. JAPMA, 95:505-507, 2005.

    Van Gheluwe B, Kirby KA, Hagman F: Effects of simulated genu valgum and genu varum on ground reaction forces and subtalar joint function during gait. JAPMA, 95: 531-541, 2005.

    Spooner SK, Kirby KA: The subtalar joint axis locator: A preliminary report. JAPMA, 96:212-219, 2006.

    Kirby KA: Emerging concepts in podiatric biomechanics. Podiatry Today. 19:(12)36-48, 2006.

    Lewis GS, Kirby KA, Piazza SJ: Determination of subtalar joint axis location by restriction of talocrural joint motion. Gait and Posture. 25:63-69, 2007.

    Pascual Huerta J, Ropa Moreno JM, Kirby KA: Static response of maximally pronated and nonmaximally pronated feet to frontal plane wedging of foot orthoses. JAPMA, 99:13-19, 2009.

    Lewis GS, Cohen TL, Seisler AR, Kirby KA, Sheehan FT, Piazza SJ: In vivo tests of an improved method for functional location of the subtalar joint axis. Journal of Biomechanics, 42:146-151, 2009.

    Pascual Huerta J, Ropa Moreno JM, Kirby KA, Garcia Carmona FJ, Orejana Garcia AM: Effect of 7-degree rearfoot varus and valgus wedging on rearfoot kinematics and kinetics during the stance phase of walking. JAPMA, 99(5):415-421, 2009.

    Kirby KA: "Evolution of Foot Orthoses in Sports", in Werd MB and Knight EL (eds), Athletic Footwear and Orthoses in Sports Medicine. Springer, New York, 2010.
  38. W J Liggins

    W J Liggins Well-Known Member

    Hi Docbourke

    Robert (OP) is being a little mischievous and actually attacking a recent paper which I sent him, extolling the virtues of a particular (unaccepted) theory and particular (unaccepted) insoles - satire and understated spoof being very much the English sense of humour.

    Much of modern foot mechanics was based on the book "Normal and Abnormal Function of the Foot" by Root, Weed and Orien, which is an excellent volume, but as in so many cases in our work, is based on theoretical concepts which are not valid in vivo. In particular, an anatomical model of 'normalcy' was proposed, which has since been shown to be fallacious, and quite a number of posters on this thread have developed alternative theories which accept the variations in sub-talar morphology which you mentioned as well as diurnal and other variation which is a particular interest of David Holland.

    The latter's Masters, incidentally, is in Bioengineering based on anthropogenic studies of the foot and leg, and I would be interested in his opinion on the 'atavistic theory'. This was held long before H P DuGillette was a twinkle in his father's eye and was proposed by the Victorians, William Ellis of Gloucester and later Norman Lake in his book "The Foot". The former was a physician and the latter an Orthopaedic Surgeon, so we have much to thank them for, even if they were adherents of the 'three point' weightbearing concept.

    I claim no great ability in the area of functional foot treatment, and am no expert unlike many of the posters on this thread. However, I reiterate my view that the individual patient should be treated according to symptoms (occasionally asymptomatic pathology) and that the concept of providing orthoses to 'everyone' is tantamount to following in the steps of the drug company who advocated the prescription of diazepam to 'everyone'.

    All the best

    Bill Liggins
    Last edited: Jul 29, 2011
  39. Rod Wishart

    Rod Wishart Member

    Well said doc bourke. 3 cheers
  40. docbourke

    docbourke Active Member

    I may have come across a little dogmatic initially only because I am constantly seeing patients in my rooms spending hundreds of dollars on worthless orthotics prescribed for reasons that are only obvious to the prescriber without heed to the symptoms of the patient. A classic example is a patient with a cavo varus foot given orthotics with a medial heel wedge forcing them further into inversion and worsening their unstable ankle and 5th metatarsal metatarsalgia or orthotics for kids with flexible flat feet and no symptoms.
    We as Orthopaedic Surgeons certainly don't limit our surgery to procedures with level 1 clinical evidence but I don't propose the widespread use of procedures indisrimanently across large populations such as the prescription of orthotics in Australia seems to have progressed to. Don't get me wrong, orthotics play a valuable role in my practice and I prescribe them everyday but I try to use sound biomechanical principals combined with common sense to provide the most effective form of treatment and if it doesn't help I am not afraid to try something different.
    My main problem is the dogmatic approach some people have to subjects that have not been fully worked out and measurement of sub talar angles/ inclination/ ROM and their relationship to foot pathology both in aetiology and treatment is one of them Theories may exist but unless Joe Average is able to transform these to viable, predictable and effective treatment in his or her rooms they remain theories.
    By the way I am happy to be called Doc or Gerard, whatever suits.

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